Inspection on 21/08/07 for Haddon (52A)

This inspection was carried out on 21st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 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) 10/04/06

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 Chris Schwarz Unannounced Inspection 21 August 2007 09:20 st Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haddon (52A) Address 52A Haddon Great Holm Milton Keynes Bucks MK8 9HP 01908 262585 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) reception@macintyre.org www.macintyrecharity.org MacIntyre Care Elaine Forbes Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th April 2006 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 organisation’s 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 £ 18000 to £39000 per year. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted over the course of a day and covered all of the key National Minimum Standards for younger adults. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion alongside comment cards for distribution to service users, relatives and visiting professionals. Any replies that were received (22 were received in time for the inspection) have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the manager, external line manager and other staff, opportunities to meet with service users, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: Prospective service users are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. Effective and detailed care plans are in place which adequately document service users’ needs and how these are to be met, within a risk assessment framework. Service users have a varied and active lifestyle which reflects their interests, provides them with nourishing meals and offers them opportunity to try new experiences and have contact with family, friends and the community. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. Thorough recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. Prospective service users are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An updated service users’ guide and statement of purpose were in place at the home, outlining the scope and philosophy of the service and how it aims to meet people’s needs. These were in good order and easy to follow. There have not been any new admissions to the service in the past twelve months, according to information supplied prior to the inspection. At the last inspection, documents relating to the most recently admitted service user were examined and found to be in good order with a detailed and comprehensive needs assessment which indicated that the service user had been involved in the process. The home does not take emergency admissions and is not registered to provide intermediate care. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 9 Service users who completed or who were assisted to complete comment cards indicated that they had been asked if they wanted to move into the home and had received enough information about it beforehand. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. Effective and detailed care plans are in place which adequately document service users’ needs and how these are to be met, within a risk assessment framework. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of service users’ personal files were read as part of the inspection and found to be in good order. Photographs of the individual were placed at the front of their files with information on their history. Copies of local authority community care plans and purchase orders were seen to be in place and notes of reviews showed that placements were being evaluated at least once a year. Staff showed an example of a new format they are using to minute reviews, using lots of photographs in order to make the notes accessible to the service user. Person centred plan folders were being kept in service users’ rooms and one person permitted access to his file to give an outline of how it had been produced. It reflected his current situation and goals for the future and was a good example of person centred working. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 11 Service users’ files provided lots of examples of people being supported to be as independent as possible, such as managing their own medication and accessing facilities in the community. Risk assessments were in place and in the process of being transferred onto a new corporate format; those risk assessments seen showed evidence of review and amendment where necessary. Meetings were being held regularly in each flat between service users and staff to share and discuss any issues and pass on news. Additionally, a fortnightly people’s forum takes place facilitated by an independent person which is open to all MacIntyre Care service users at the Great Holm site. Service users were seen to make decisions during the inspection, such as what to make for lunch, going out to get a top up mobile telephone card, arranging to see family at the weekend, as well as verbal testimony during conversations. It was positive to see recorded on one person’s file that they had been receiving support from an outside agency regarding sex education, additionally a meeting took place during the inspection involving another service user and her care manager from the local authority to discuss plans to move on with her partner. Service users’ money was being well managed overall with individual wallets kept secure and transaction sheets to record expenditure. Receipts were in place to verify purchases and staff explained that there are different levels of authorisation needed for spending above £50, acting as a safeguard for service users’ finances. Reports of the provider’s monitoring visits showed that service users’ money is checked routinely as part of the visit, which is a good practice. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. Service users have a varied and active lifestyle which reflects their interests, provides them with nourishing meals and offers them opportunity to try new experiences and have contact with family, friends and the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are involved in a number of activities, mainly locally based at Great Holm. People met during the course of the inspection described involvement in a coffee shop, bakery, the garden centre next door and taking part in craft, drama and computer classes. There was also opportunity for those who were interested to develop office skills and undertake a National Vocational Qualification working at the provider’s central headquarters. In service users’ rooms there was evidence of interest in football, listening to music and watching DVDs and several people said they had their own mobile telephones in addition to the payphones in the flats. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 13 Service users’ were seen to have keys to their doors and had freedom to be alone in their rooms or in the communal areas. Each flat that was seen had its own menu drawn up by service users and individual needs, such as vegetarian meals, were being met. One service user said additionally on their comment card that they liked the food at the home. One relative who completed a comment card said that help was being offered to a service user who needs support to lose weight. People completing comment cards said that the home generally helps them keep in touch with family and friends. One relative mentioned that his son has a mobile telephone to keep in contact with family members. Comments included “Staff always keep us informed about any decisions that need to be made and involve our daughter in these where appropriate.” “The service is continually finding new challenges for our daughter so that she can reach her full potential.” A relative responding to the question what do you think the care home does well, considered that it enabled their daughter “to live a relatively independent life under the protection of the MacIntyre umbrella. Providing her with a variety of daily activities which improve her skills.” Another person said “He had been well cared for at 52A Haddon and has been taught domestic skills. He lives a satisfying life and enjoys being with the many friends he has made in MacIntyre. Another relative commented “She enjoys her life at MacIntyre. Her work timetable is varied – her hours have changed over the last couple of years as she has found full days quite tiring. This has been taken account of.” The relative added that “I sometimes feel they should be encouraged to take part in a wider range of activities at the weekend – outings etc. While she would happily sit in front of the television I feel that she would enjoy, and it would be of benefit to her, if she were out and about more.” Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ personal and healthcare needs were recorded in support plans. Where applicable, staff were maintaining records of seizures and individual protocols were in place for using oral diazepam. Records of health care appointments were being noted, showing that routine and specialist medical advice is sought and a member of staff was observed arranging a prompt dental appointment for the next day as a service user was experiencing some pain. It was encouraging to see that service users were being supported to access Well Man and Well Woman checks. People who completed comment cards generally felt that the home always or usually provides service users with the support they require. Comments included “Provides a total lifestyle to the best of their ability and maximises the individual’s capability.” Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 15 A relative said the service “looks after everyone well”. Another person said “Any problems with his health are dealt with immediately.” A relative explained that there had been some health care issues for one of the service users which the hospital had not picked up or responded to promptly enough and added “While MacIntyre were not to blame they did not actively work to sort the matter out. As there is a high turnover of staff and keyworkers attached to residents, I feel that some concerns are passed over and an individual may not be aware of a resident’s history.” Another relative said “My son is very happy there…he regards it as his home.” One person considered that staff needed to offer more support to encourage service users to change clothes when necessary and to shave properly. During the inspection, a member of staff was observed gently reminding a service user to shave before going off to work. A general practitioner indicated that the home communicates clearly and works in partnership with the surgery, that they are able to see patients in private, that staff demonstrate an understanding of care needs and specialist advise is incorporated into care plans. There was indication that medication is being managed appropriately and that the doctor was satisfied with the overall care provided to service users at the home. Several service users were managing their own medication and had individual locked cabinets in their rooms. They were able to describe, without being asked, what their medicines were being taken for. Risk assessments were in place to support service users. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. Procedures for managing complaints and adult protection are in place but need some minor revision to ensure people have accurate information to hand. Management of records in this area needs some improvement, to ensure clear audit trails and to safeguard sensitive material. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most people completing comment cards were aware of how to make a complaint about the service. Those who had needed to raise issues added that the service had responded appropriately. A relative said that her daughter “has always been very happy and when problems have occurred the staff have worked to sort them out.” The service had a complaints procedure. This needed some revision as although produced in 2003 it referred to out of date legislation, The Registered Home Act of 1984, and was not explicit in informing complainants that the Commission may be approached directly if they have any concerns or complaints and the contact details. A requirement is made to address this. Four complaints were noted in the pre-inspection self assessment, one of which had been upheld. No complaints had been made directly to the Commission by service users or their representatives. The complaints log was not well arranged, with pieces of paper stapled to handwritten pages and some Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 17 information contained within envelopes which was also stapled to pages. There was also confidential material (relating to a service user at another home) from a strategy meeting stapled into the complaints log, which was freely accessible in the office. A recommendation is made to manage records of complaints in a more orderly manner and a requirement made to keep confidential information secure. There were adult protection procedures in place. These referred to out of date legislation and referred staff to the “registering authority”. Updating is needed to amend the legislative background, if the policy is to mention this, and to make sure that staff know that they are to report adult protection matters to the Commission. One adult protection referral had been made in the past year, according to information supplied before the inspection. At the previous inspection a requirement was made for the staff team to undertake training in safeguarding/protecting adults from abuse. Records at the service showed that this had been attended to in most cases, with courses due to take place soon for any remaining staff. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. Improvement has been made to some of the flats to provide more pleasant surroundings for service users, although there is still unacceptable risk from the practice of doors being held open. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service consists of five flats, numbered 44 to 52 Haddon in Great Holm. Four of the flats provide accommodation for small groups of service users, the fifth is for single occupancy. The staff office is separate to the flats although very close by. From Great Holm, service users have good access to the facilities within Milton Keynes city centre and there are good transport links. Three of the five flats were toured as part of this visit and service users were asked permission by staff for entry. Several service users offered to show their rooms so that size, layout and facilities could be assessed. Most of the bedrooms were particularly small but personalised by service users and they said they had chosen paint colours. Storage was highlighted as an issue at the Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 19 previous inspection and was yet to be resolved; a member of staff discussed a prospective solution for one of the upstairs flats, making use of some of the communal space. New kitchens had been fitted in two of the flats seen and a new bathroom in one. Service users were pleased with the results and liked the new shower that had been installed. Lounges were homely in appearance and looked bright and comfortable. Radiators in one of the flats that needed to be covered to prevent accidental injury had been attended to. A number of comments were made about the environment via surveys cards. A relative commented “I feel additional help is needed with cleaning. She is not capable of giving the bathroom a good hygienic clean. On some visits I have found the bathroom in a disappointing state.” Another relative said “His wash basin is often unhealthily dirty and under his furniture does not get vacuumed and often is a storage place for old food or dirty coffee mugs.” One respondent commented that the toilet in 48 Haddon is not kept clean or well stocked with toilet roll and hand washing items. There was some evidence of a need to provide service users with more support than they currently receive to keep the environment maintained to reasonable and hygienic standards. Most parts of the flats that were seen were in good order but some attention to deeper cleaning is needed, and was acknowledged by staff. A requirement was made to this effect at the previous inspection and needs to be fully implemented by staff. Of particular concern was the continuing practice of using wedges or other items to keep bedroom doors open. Devices have been fitted to some doors although these were additionally being held open, rendering them useless in the event of a fire. The manager said that in the flats which were not viewed, doors were also being held open. Enforcement action will be taken by the Commission if this practice does not cease. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. The home provides staff cover to meet needs although on some occasions levels have dropped due to unforeseen circumstances. Thorough recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a small group of staff providing support and care to service users, just under half of whom have achieved National Vocational Qualification level 2 or above. Further staff are working towards the qualification. Four staff had left in the twelve months prior to the inspection which is a significant number for a small team. At the time of the inspection, the home was not needing to use any agency staff to help cover the rota. The manager had notified the Commission of six occasions since January this year when staffing levels had dropped to one carer working part of a shift to 14 service users, either due to people ringing in sick or needing to take service users to hospital. Whilst service users’ personal care needs are low they require supervision at the peak times when these levels dropped and some degree of risk may have been present at these times. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 21 The staff who were met during the inspection were knowledgeable and presented as good advocates for service users. One person who was keyworker to a service user whose care plan was examined, conveyed a positive approach to working with the person, treating them as an adult and fully promoting independent living. Main recruitment files are held at the provider’s headquarters in central Milton Keynes and show that all necessary clearances have been received. One new member of staff was waiting to start work, pending full clearance. Training records were incomplete at the service. Copies of certificates from courses attended had not been collated for each person working at the service therefore it was not possible to say with certainty that the requirement made at the last inspection, regarding updating mandatory training, had been met. The manager will need to address this to ensure that there is clear evidence of the requirement being fully met. She may wish to consider setting up individual training matrices for each person to supplement the certificates. A requirement made at the previous inspection, 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, had been ignored. A recommendation to review staffing levels at the service had not been actioned. It was difficult to see, given that the day of the inspection was not an exceptional day, how staff could sustain working with just two people on plus working in a cramped office with poor natural light and little ventilation. It was noted that the manager was needing to keywork one of the service users, which would be detracting from time more usefully spent managing the service. The recommendation is repeated on this occasion. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. Management and line management of the home are not acting to fully improve quality of care and to ensure that risk is safely managed to reduce the likelihood of injury or harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a registered manager who has attained National Vocational Qualification level 4; her post comes with a job description outlining duties and responsibilities. She reports to an external line manager who carries out her supervision and also undertakes monitoring visits on behalf of the provider. Reports of monitoring visits followed a detailed format and showed that speaking with staff and service users is a regular feature of the visits, plus good practices such as examining a sample of service users’ money and staff training records. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 23 Five requirements have been repeated from the previous inspection which have not been dealt with as part of monitoring visits or attended to by the manager herself, where able. Both parties need to ensure they fully meet their responsibilities toward the service and in complying with legislation. A continued failure to attend to requirements is likely to lead to enforcement action being taken and has implications for individual’s continued registration. At the last inspection it was noted that a service user satisfaction questionnaire has been sent out to individuals and a request was made for a copy of the published results of the survey to be sent to the Commission. This had not been done. The manager said that the findings had not been collated into a report, which leaves the exercise open ended. Should a further exercise be carried out this year, it would be expected that a registered manager collate the findings as part of their professional role and share these with the people who took part and relevant parties. A range of health and safety checks was in place at the service, carried out on a daily, weekly or monthly basis. Portable electrical appliances had been checked in September last year, electrical hardwiring was checked in December 2002 and each flat had a current gas safety certificate. Following a visit by the fire officer at the start of the year, remedial action was needed to improve fire precautions. There was verbal testimony by the manager and her line manager to say works had been carried out by a suitable person but no proof was evident such as an engineer’s invoice. This needs to be attended to. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 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 2 x 2 x x 2 x Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 25 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 YA22 Regulation 22 Timescale for action A revised complaints procedure 01/11/07 is to be produced (with reference to current legislation if legislation is referred to) including the name, address and telephone number of the Commission. Confidential material about 15/09/07 service users is to be kept secure. The adult protection policy is to 01/11/07 be updated to reflect current legislation (if legislation is referred to) and to make explicit to staff that they are to report adult protection matters to the Commission. Bedrooms doors are not to be 15/09/07 held open by door wedges or other items. Only devices approved by the fire officer may be safely used. Previous timescales of 30/11/05 and 30/06/07 not met. Suitable storage facilities are to 01/11/07 be provided for the use of service users. Previous timescales of 30/03/06 and 30/06/07 not met. DS0000039068.V339299.R01.S.doc Version 5.2 Page 26 Requirement 2 3 YA23 YA23 17(b) 13(6) 4 YA24 23 5 YA24 23 Haddon (52A) 6 YA30 23 7 YA35 18 8 YA35 18 9 YA42 23 Service users are to be provided with extra support to carry out in depth cleaning of their flats. Previous timescale of 30/09/06 not met. All care staff are to attend and update all mandatory training as necessary. Previous timescale of 30/07/06 not met. The Commission is to be provided with details of all relief staff employed, line managers and confirmation that necessary training, formal staff supervision and annual appraisals are being completed. Previous timescale of 30/05/06 not met. Proof is needed that the required works outlined by the fire officer have been carried out, as outlined in his report. 15/09/07 01/11/07 30/09/07 01/10/07 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 YA22 YA33 Good Practice Recommendations The complaints log is to be better managed to provide a clear and professional audit trails of how complaints have been responded to. Serious consideration is to be given to increasing the staffing ratios in the unit to allow staff to fully meet the needs of service users. Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haddon (52A) DS0000039068.V339299.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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