Inspection on 10/04/06 for Haddon (52A)

This inspection was carried out on 10th April 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 (52A) 22/08/08

Haddon (52A) 21/08/07

Haddon (52A) 04/10/05

Haddon (52A) 05/08/05

Haddon (52A) 16/01/04

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 (52A) 52A Haddon Great Holm Milton Keynes Bucks MK8 9HP Lead Inspector Barbara Mulligan Unannounced Inspection 10th April 2006 09:30 DS0000039068.V288802.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 DS0000039068.V288802.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. DS0000039068.V288802.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Haddon (52A) Address 52A Haddon Great Holm Milton Keynes Bucks MK8 9HP 01908 230100 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 Elaine Forbes Care Home 15 Category(ies) of Learning disability (15) registration, with number of places DS0000039068.V288802.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th December 2005 Brief Description of the Service: Set on the edge of Great Holm, 52A Haddon, owned by Macintyre Care, is located within a campus style complex, in amongst private housing. It provides accommodation to adults with learning disabilities. 52A 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 numbers, 42A and 32A Haddon, the organisations day care services, a hall, a nursery and garden centre, a craft shop, a coffee shop and a bakery. 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 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. DS0000039068.V288802.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 10th April 2006 at 9.30am on a Monday morning. The visit consisted of discussions with the registered manager, service users and staff, a tour of the premises, and records and documentation were examined. The inspection officer was Ms. Barbara Mulligan. The registered manager was Elaine Forbes. Twenty-nine of the National Minimum Standards were assessed during this visit. Twenty-two of these are fully met and seven almost met. As a result of the inspection the home has received ten requirements. What the service does well: What has improved since the last inspection? Care planning documentation has improved and it is pleasing to see that most files have been reviewed and now reflect the changing needs and personal goals for service users. At the previous unannounced inspection in October 2003 the manager said that a parent’s forum had recently been implemented. However, this had ceased after just one meeting. It is pleasing to see that a date has been set for this to re-commence, thus ensuring the views of family, friends and advocates and of stakeholders in the community are allowed to be aired and taken into account. During a tour of the flats it was evident that there is an improvement in the general cleanliness of the flats. DS0000039068.V288802.R01.S.doc Version 5.1 Page 6 Following the previous inspection it was required that the registered manager is made supernumerary at 52A Haddon to allow for time spent at two supported living schemes for which she was responsible, or the two supported living schemes are relinquished. It is very pleasing to see that the manager is no longer responsible for the two supported living schemes and is able to undertake her role as registered manager for the unit on a full time basis. Service users and staff spoken to said that this has been beneficial to the unit. Staff are no longer expected to work hours allocated for 52 A Haddon at the supported living schemes and again staff and service users said that this has proved beneficial. What they could do better: Staff training needs to be brought up to date for all relief staff and the unit needs to be staffed sufficiently to allow staff time off to attend necessary training. The registered provider needs to ensure that relief staff have an identified line manager who will be responsible for their formal supervision, annual appraisals and for putting relief staff forward for essential training. There were no relief staff on duty to assess if this has been complied with. The inspector requests that the organisation provide the Commission with details of all relief staff employed, identified line managers and confirmation that relief staff have received up to date training, supervision and appraisals. Serious consideration needs to be given to suitable storage facilities for service users in their flats to prevent them from being cluttered. Of serious concern is the practice of several service users wedging bedroom doors open with various items such as a sweat shirt, a wooden board and a bed. A requirement was made following the previous inspection that a more suitable system is implemented for keeping bedroom doors open to prevent the use of door wedges. Although electronic door guards have been fitted to some doors it was observed that the practice of wedging doors open still persists. This is a dangerous practice and potentially a fire hazard. It will be a requirement of this report that suitable systems are implemented for keeping bedroom doors open. During a tour of the flats it was evident that there is an improvement in the general cleanliness of the flats. However, it is noted that service users require extra help with more in-depth cleaning such as the cooker and washing spills on the walls and skirting boards. There is an induction programme in place. However, it is noted that there is a considerable time lapse before staff have undertaken all necessary training required at induction. An example of this is one staff member who has been employed for six months but has not yet received basic food hygiene training. This member of staff is expected to prepare and support service users to prepare meals. This should not be undertaken unless the staff member has completed basic food hygiene training. It is a requirement of this report that staff receive the necessary training at induction, before they are required to carry out tasks for which they are not trained. DS0000039068.V288802.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. DS0000039068.V288802.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 DS0000039068.V288802.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): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide requires review and updating in order that they provide potential service users with details of the service and needs to be reviewed and updated as necessary. 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. Individuals are given the opportunity to visit the home prior to admission as an integral part of the admission process, which means that service users are orientated to the environment and have met and are familiar with staff and other service users beforehand. All service users have a written, individual service contract ensuring that there is an understanding of the homes terms and conditions. EVIDENCE: The Service Users Guide and the Statement of Purpose are dated 2003 and need to be updated. One service user has been admitted to the unit since the previous unannounced inspection on 3rd October 2006. 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. DS0000039068.V288802.R01.S.doc Version 5.1 Page 10 The home has a policy called “Moving in and Moving out guidelines”. This is dated June 2003 and gives details of trial visits to the unit, 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 format suitable for service users. All service users have a 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. DS0000039068.V288802.R01.S.doc Version 5.1 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 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 most care plans adequately provide staff with the information they need to satisfactorily meet service users needs. However, several care plans still need to be fully completed to ensure staff are working from current information. Service users make decisions about their lives, with assistance and communication support, that allows them to influence their lifestyle and how the home is run. 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: A random selection of service user plans were examined during the inspection and it is pleasing to see that most 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 DS0000039068.V288802.R01.S.doc Version 5.1 Page 12 individuals are met. However, not all service users plans have been updated to include this information and this will be a requirement of the report. 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, 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. 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. DS0000039068.V288802.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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: DS0000039068.V288802.R01.S.doc Version 5.1 Page 14 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. Day services provide opportunities for further education and this may be in IT skills, food hygiene, literacy skills and money management. 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. 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. Evidence was seen in the care plans and confirmed through discussions held with service users. Individuals vote, and do so by proxy or by attending the local polling station on voting day. Electoral cards were observed at the time of the inspection due to the upcoming election. 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/or their partners visit them and are able to stay. Staff assist service users to make regular phone calls and to write letters to family and friends. Many service users have their own mobile phones. At the previous unannounced inspection on October 3RD the registered manager stated that a parent’s forum had recently been implemented. However, this had ceased after just one meeting. It is pleasing to see that a date has been set for this to re-commence, thus 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 were “ very helpful and kind” and “they help me a lot”. Housekeeping rotas are kept in individual’s flats and some of these are in picture form. These include such tasks as cooking the evening meal, washing up and cleaning. DS0000039068.V288802.R01.S.doc Version 5.1 Page 15 Service users choose their own menus at their flat meetings. One service user pointed out that it was his turn to cook the evening meal and said” I like cooking dinner for everyone”. 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. Service users are weighed regularly and this is recorded in their care plans. DS0000039068.V288802.R01.S.doc Version 5.1 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 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 plans. Personal support is provided either in bedrooms or bathrooms. However, independence is encouraged and prompting given. One service user spoken to on the day of the visit indicated that he had chosen his own hairstyle and sometimes went out with his key worker in order to buy new clothing, toiletries and other personal effects. He also confirmed that he is involved in all reviews that pertain to him and that he is enabled to make decisions about his needs. The service user also confirmed that group decisions are made in relation to the running of the flat such as menu planning and meal preparation and that all staff are supportive and facilitative. There is evidence on file of the healthcare support available to service users and it was clear that routine appointments are attended in line with NHS entitlements and all initiatives recorded. Service users receive additional support through the Learning DS0000039068.V288802.R01.S.doc Version 5.1 Page 17 Disabilities Community Team, where they can access physiotherapists, occupational therapists, speech therapists and other specialist services they may require. The unit operates a key worker system. Service users are encouraged to self-administer their own medication and risk assessments are in place for this. Following the previous unannounced inspection there was evidence that one service user had epilepsy and occasionally required a rectal stesolid. Staff training in this area was not adequate and a requirement was made. However staff are no longer required to administer this and the requirement is no longer needed. The inspector looked at a record of current medication kept for each service user. These are completed accurately and there were no omissions noted. The home uses a monitored dosage system. Unused medication is disposed of via the pharmacy. There are no controlled drugs in use. The registered manager stated that a nearby pharmacist was now carrying out medication training. Overall, the storage and administration of medications was found to be good. A minimum number of medications were held in the home, they were stored in an appropriate facility and all were within their ‘use by’ dates. DS0000039068.V288802.R01.S.doc Version 5.1 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 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. However, staff spoken to stated that they had not received up to date training regarding the protection of vulnerable adults which could put service users at risk. EVIDENCE: DS0000039068.V288802.R01.S.doc Version 5.1 Page 19 There is a complaints procedure dated March 2003. This is in pictorial/photo form in the staff office and 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, however no complaints have been received since the previous inspection. 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 were 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 not all staff were up to date with POVA training. This will be a requirement of this report. During the previous unannounced inspection on the 3rd October 2005 it was apparent that relief staff do not attend regular training regarding the Protection of Vulnerable Adults and this was made a requirement of the previous report. However, during this inspection, there were no relief staff available to talk to. It is a requirement of this report that confirmation is sent to the Commission that all relief staff have completed and are up to date with POVA training. 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 gifts procedure that provides staff with guidelines about receiving personal gifts from service users. DS0000039068.V288802.R01.S.doc Version 5.1 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 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 adequate. This judgement has been made using available evidence including a visit to this service. 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 remain 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: There are five flats within 52 A Haddon. The inspector undertook a tour of individual flats at lunchtime. Many service users were out at work at the time of the inspection and personal bedrooms were not observed if the service users were not at home. During a tour of the flats several bedroom doors were observed to be propped open with various items, which included a sweatshirt, a wooden board, a wooden wedge and a bed. A requirement was made following the previous unannounced inspection that a more suitable system is implemented for keeping bedroom doors open to prevent the use of door wedges. Although DS0000039068.V288802.R01.S.doc Version 5.1 Page 21 several doors have had electronic door opening guards fitted there still remain a number of bedroom doors that need to be fitted. This will be a requirement of the report. Flat 52 is nicely decorated, homely, bright and cheerful. However the worktops in the kitchen are very worn and need replacing. There is a minimum amount of cupboard space and it would benefit from a new fitted kitchen. This was a requirement of the previous report and will be a requirement of this report. The bathroom is in need of some redecoration and service users stated that they would like a new floor in the bathroom. Flat 48 is nicely decorated, homely, bright and cheerful. The carpet in the hallway was observed to be grubby and requires cleaning. It was pleasing to see that the kitchen and worktops have been replaced. Services users living in this flat told the inspector they would like a shower installed. It is pleasing to see that some repairs to the bathroom have been completed since the previous inspection. Several bedrooms were observed to be cluttered. Two service users living in flat 48 told the inspector that they would like a bigger bedroom with more storage space. Flat 50 was again nicely decorated, homely, bright and cheerful. The kitchen and the kitchen flooring have been replaced and are now spacious with plenty of storage space. The toilet on the upper floor had been leaking and mildew /mould had developed at the back of the toilet. It is pleasing to see that this has been repaired. The radiator in the bathroom was very hot to touch but was not covered with a low surface temperature cover. Tiling around the hand basin was in a state of disrepair and needed to be repaired. These repairs will be made requirements of the report. The single toilet has a small radiator that is not covered, but is again hot to touch. It will be a requirement of this report that the radiator is either covered or the temperature reduced. Flat 44 is home to two service users. It is pleasing to see that the flooring in the kitchen has been replaced. The kitchen has been cleaned but is in need of some redecoration. One service user who lives in this flat told the inspector that the hallway and the kitchen are due to be repainted and colours have been chosen. The service user also said that he would like a larger lounge. The toilet has been effectively cleaned. Flat 46 has been refurbished to include a new bedroom. The lounge remains cluttered. However, efforts have been made to make the lounge area comfortable and liveable as required at the previous inspection. The flooring in the kitchen is laminated wood and has been repaired around the dustbin area as required at the previous inspection. It is pleasing to see that repairs to the bathroom flooring have been completed. DS0000039068.V288802.R01.S.doc Version 5.1 Page 22 There remains a general lack of storage space within all the flats, resulting in clutter in many bedrooms, lounges and hallway alcoves. This needs to be addressed and was a requirement of the previous report. This will be a requirement of this report. It was observed that generally cleanliness of the flats has improved. However, extra support is required for more in depth cleaning such as cleaning of cookers, washing skirting boards and walls where spills are evident. This will be a requirement of the report. DS0000039068.V288802.R01.S.doc Version 5.1 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment benefits from robust organisational policies, procedures and systems that meet all legislative requirements and ensure the safety and protection of service users. While the range of staff training and development offered via MacIntyre Care is good, access to this training is difficult which results in necessary training not always being up to date which does not ensure staff are appropriately equipped to deal with service users’ issues or able to manage their care effectively. EVIDENCE: At the previous unannounced inspection it was decided by the organisation that documentation for staff recruitment was to be kept at a central office. The unit now holds some original documentation for staff employed over six months and copies or other evidence for newly employed staff. A random selection of staff files/documentation were looked at during the visit. These contain the necessary details as detailed in Standard 34 and Schedule 2. All clearances including appropriate references and CRB checks are in place. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities. However, it is noted that there is a considerable time lapse before staff have undertaken all necessary training required at induction. An example of this is DS0000039068.V288802.R01.S.doc Version 5.1 Page 24 one staff member who has been employed for six months but has not yet received basic food hygiene training. However, this member of staff is expected to prepare and support service users to prepare meals. This should not be undertaken unless the staff member has completed basic food hygiene training. Unless care staff receive the necessary training at their initial induction they will not be appropriately equipped to deal with service users’ issues or meet their needs appropriately. It is a requirement of this report that staff receive the necessary training at induction, before they are required to carry out tasks for which they are not trained. Further training for staff includes First Aid, Basic Food Hygiene, Moving and Handling and Fire Awareness. However, in discussions held with staff it was apparent that training is not updated regularly for permanent staff and in particular relief staff. This was a requirement of the previous report and will remain a requirement of this report. It was identified at the previous unannounced inspection that relief staff did not have an identified line manager who was responsible for their formal supervision, annual appraisals and for ensuring that their training was up to date. There were no relief staff on duty to confirm if they have received refresher or up to date training, supervision or an annual appraisal. The inspector requests that the organisation send details to the Commission of all relief staff employed by the organisation, confirmation that they have identified line managers and evidence that training, formal staff supervision and annual appraisals are being completed for all relief staff. This will be a requirement of this report. DS0000039068.V288802.R01.S.doc Version 5.1 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome is adequate. 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. Overall, health and safety procedures are in place, however serious consideration needs to be given to alternative ways to keep bedroom doors open without using door wedges, ensuring the safety of service users. EVIDENCE: The registered manager has been employed by MacIntyre Care for 14 years, and has been in post as manager for approx 6 years. She is presently undertaking her NVQ level 4 training and is near to completion. Examples of further training undertaken by the registered manager include Disciplinary and Investigations, Risk Assessments, Fire Awareness and Health and Safety training. MacIntyre Care uses several methods for ensuring the quality assurance of the unit. The unit complies with the requirements of the Care Homes Regulations DS0000039068.V288802.R01.S.doc Version 5.1 Page 26 2001 and submits a record of the Regulation 26 visit by senior management of the organisation each month. The outcome of the visit is recorded on a pre printed pro forma and meets the criteria for required information, in line with the Standard. The registered manager stated that a service user satisfaction questionnaire has been sent out to individuals within the last two weeks but had not been returned. The inspector requests that a copy of the published results of the survey is sent to the Commission. 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. Service users have monthly flat meetings. 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. Service users’ needs are reviewed on an annul basis or more often, as required. Evidence of these was noted via review notes that are held on the individual plans of care. Health and Safety systems in place within the home are checked on a regular basis and records maintained. Fire alarm testing is undertaken weekly and fire drills are carried out with the full involvement of the service users. During a tour of the flats several bedroom doors were observed to be propped open with various items, which included a sweatshirt, a wooden board, a wooden wedge and a bed. A requirement was made following the previous unannounced inspection that a more suitable system is implemented for keeping bedroom doors open to prevent the use of door wedges. Although several doors have had electronic door opening guards fitted there still remain several bedroom doors that need to be fitted. This will be a requirement of the report. The unit has an infection control policy that is detailed and comprehensive. There is evidence that Health and Safety Checks are carried out quarterly and a Generic Health and Safety risk Assessment was observed. The registered manager said that servicing for gas appliances has taken place recently but the unit has not received the certificates. There is evidence in the unit’s diary/communication book that this has been undertaken. Certificates seen for PAT testing are dated 23/09/05. There is evidence of water temperature recording, work placement risk assessments, accident and incident reports, health and safety risk assessments and the maintenance of electrical systems and electrical equipment. Hazardous substances are stored appropriately and the COSHH sheets were looked at. These were observed to be up to date. DS0000039068.V288802.R01.S.doc Version 5.1 Page 27 Mandatory training is not up to date for all permanent staff and newly appointed staff were working in the unit but had not received fire training, moving and handling training, first aid and basic food hygiene training. This has been made a requirement of the report. The staff office and sleep in area are small and lack storage space. Staff spoken to said that they found it difficult to find a suitable space to undertake paperwork and staff supervision. At the previous unannounced inspection difficulties were being experienced with records that needed archiving. There was no room to do this within the unit and it was recommended that the registered provider give serious consideration to suitable storage facilities for the storage of old/archived records. This has now been resolved and archiving is being completed twice a year. DS0000039068.V288802.R01.S.doc Version 5.1 Page 28 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 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 X DS0000039068.V288802.R01.S.doc Version 5.1 Page 29 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4&6 Requirement The registered manager is required to ensure that the Statement of Purpose and Service Users Guide are reviewed and updated and a copy sent to the commission. The registered manager is required to ensure the remaining care plans are completed to reflect all the changing needs and personal goals for service users and ensures all aspects of the health, personal and social care needs of individuals are met. The registered manager is required to ensure that all care staff who work in the unit receive POVA training or are up to date with POVA training. (Previous timescale of 30/12/05 not met) The registered provider is required to ensure that a more suitable system is implemented for keeping bedroom doors open to prevent the use of door wedges. (Previous timescale of 30/11/05 not met) The registered provider is required to ensure that the work tops and kitchen in flat 52 is DS0000039068.V288802.R01.S.doc Timescale for action 30/05/06 2. YA6 15 30/06/06 3. YA23 18 & 13 30/07/06 4. YA24 23 30/06/06 5 YA28 23 30/08/06 Version 5.1 Page 30 6 YA28 23 7 YA24 23 8 YA30 23 9 YA35 18 10 YA35 18 replaced. (Previous timescale of 30/09/05 and 30/03/06 not met.) The registered provider is required to ensure that the radiator in the bathroom and toilet of Flat 50 are either covered or the temperature reduced and the tiling around the hand basin in the bathroom is repaired. The registered provider is required to ensure that suitable storage facilities are provided for the use of service users. (Previous timescale of 30/03/2006 not met) The registered manager is required to ensure that service users receive extra support to carry out in depth cleaning of their flats. The registered manager is required to ensure that all care staff attend and update all mandatory training as necessary. The registered provider is required to provide the Commission with details of all relief staff employed, line managers and confirmation that necessary training, formal staff supervision and annual appraisals are being completed. 30/06/06 30/06/06 30/09/06 30/07/06 30/05/06 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 YA33 Good Practice Recommendations It is recommended that serious consideration be given to increasing the staffing ratios in the unit to allow staff to DS0000039068.V288802.R01.S.doc Version 5.1 Page 31 fully meet the needs of service users. DS0000039068.V288802.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000039068.V288802.R01.S.doc Version 5.1 Page 33 - 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. 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