Inspection on 04/10/05 for Haddon (52A)

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Haddon (52A) 22/08/08

Haddon (52A) 21/08/07

Haddon (52A) 10/04/06

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 3rd October 2005 10.15 Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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.V255730.R01.S.doc Version 5.0 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.V255730.R01.S.doc Version 5.0 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) MacIntyre Care Elaine Forbes Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th August 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 no. 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 nursery, garden centre and craft shop also provide occupational activities for service users and are open to the public.The centre of Milton Keynes is close by, offering a large shopping centre, cinema, a range of restaurants and recreational activities, cycle tracks and many other attractions. Service users are encouraged and supported to use public transport to which they have access. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 3rd October 2005 at 10.30am on a Monday morning. The visit consisted of discussions with the registered manager and records, policies and procedures were examined. Concerns regarding staff shortages were raised during an unannounced inspection carried out on the 5th August 2055, so this unannounced inspection has been undertaken within a short period of time from the previous inspection, to assess that requirements regarding staffing have been met. What the service does well: What has improved since the last inspection? What they could do better: The staff team are caring and motivated but their numbers need to be increased if they are to fully meet the health care and social care needs of individuals. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 6 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. The main concern during this inspection is that a requirement; made following unannounced inspections on the 31st March 2005 and 5th August 2005; for the registered provider to ensure the head of service is either made supernumerary at 52A Haddon to allow for time spent at the other supported living schemes, or the two supported living schemes are relinquished by the head of service. The registered provider has failed to comply with this requirement and a further requirement made regarding hours allocated for 52A Haddon are utilised in this unit and not in another establishment. Again the registered provider has failed to comply with this requirement and the Commission for Social Care Inspection will consider enforcement action if they do not improve following this report. Serious consideration needs to be given to suitable storage facilities for service users in their flats to prevent them from being cluttered and to the storage facilities available for the storage of old/archived records. Serious consideration needs to be given to providing service users with comprehensive, accessible, understandable and up to date information, in a suitable format about policies, procedures, activities and services. There was no evidence that work has been carried out in this area and there was nothing available to look at. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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.V255730.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The homes Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides. Pictorial guidance is included to make both documents suitable for the people for whom the home is intended. Each service user has an individual written statement of terms and conditions that is signed by service users or relative or relevant third party and the registered manager. EVIDENCE: Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 9 The Service Users Guide is well presented and informative and this document covers all the necessary information as detailed in standard 1. However, this does not appear to have been reviewed and changes made as necessary and is recommended. The Statement of Purpose covers all areas as detailed in Schedule 1. No service users have been admitted to 52A Haddon during the previous twelve months. All specialised services offered are accessed through the Learning Disabilities Community Team and the head of service stated that the unit has a good working relationship with the team. Random selections of staff files were looked at and there was evidence that staff training was appropriate to deliver the services and care required of the unit. The numbers of staff in the unit is minimal. The unit are unable to meet the needs of service users at weekends if they require staff support to attend activities. Staffing levels need to be reviewed to accommodate this and is a recommendation of the report. Service Users are informed about independent/self advocacy groups, and examples given to the inspector of local groups were Milton Keynes Advocacy and People First. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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, 8, 9 and 10. There is no clear or consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Service users feel that they are treated with respect and dignity and that their right to privacy is upheld ensuring personal care is delivered appropriately. 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 the home’s 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. Preferred terms of address are included in service users plans. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 11 Several care plans were examined. These include contracts, a pen picture, health check records and information regarding family/friends contacts. However, each plan of care contains approximately three personal goals for each service user. It is a requirement of the report that service users individual care plans 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. Risk assessments were observed with regard to service users who selfadminister 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. 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 each have a bank account and their benefits are paid into their own individual accounts. Service users are offered opportunities to participate in the day-to-day running of their flats. This was confirmed in discussions held with individual service users. There is a service users forum that individuals can attend and are held on a fortnightly basis. These are 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. Day services provide training and tuition to service users regarding personal safety. The inspector looked at a Health and Safety manual that contained guidelines for missing persons and this was dated 13/06/2003. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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): 11, 12, 13, 14, 15 16 and 17. Links with the local community are good which support and enrich service users social and educational opportunities. Service users engage in appropriate leisure activities inside and outside of the home, allowing individuals to pursue their own interests and hobbies. Staff support service users to maintain family links and friendships inside and outside the home. The staff have a good understanding of the service users support needs. This is evident from the positive relationships, which have been formed between the staff and service users. Service users rights are respected and the daily routines of the home promote individual choice and freedom of movement. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 13 EVIDENCE: Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 14 Service users have opportunities to maintain and develop social, emotional, communication and independent living skills through training carried out with the unit staff and day services staff. This includes menu planning, cookery, shopping and bus training. Some service users go to college to learn social skills and life skills. This may include literacy skills, money management, sex education, advocacy, fire training and relationship discussions. Most service users go to work and this may be on site, where there is a coffee shop, a craft shop and a nursery. Day services provide opportunities for further education and service users also attend the local college. 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. Relations with the neighbours are positive and there has been no problems encountered. Service users have access to transport and use taxis, buses, dial-a-ride and trains and evidence was seen in the care plans and through discussions held with service users. Individuals vote, and do so by proxy or by attending the local polling station on voting day. Staff recognise that time spent with service users outside the unit, including weekends and evenings, is part of their staff duties. Care plans show that service users are encouraged and supported to pursue their own interests and hobbies. Examples of these are football, swimming, dance, the gateway club, the cinema and horse riding. Where necessary, appropriately trained staff support and advice the service users. Each service user has access to a television and music systems. They own extensive video and C.D. collections. Service users enjoy an annual holiday and those service users who do not wish to have an annual holiday enjoy day trips and weekend breaks. There are no restrictions about family and friends visiting. The unit has a lot of contact with families and friends of service users. Staff assist service users to make regular phone calls and to write letters to family and friends. Service users can chose whom they see and when, and can see visitors in their rooms and in private. There was a parent’s forum that had recently just been implemented. However, this has ceased after just one meeting and there does not appear to be any system to obtain the views of family, friends and advocates and of stakeholders in the community. This will be made a requirement under standard 39. All service users have keys to the front doors of their flats and each flat has its own doorbell. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 15 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. Housekeeping rotas are kept in individual’s flats and some of these were in picture form. 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. Service users are weighed regularly and recorded in care plans. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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 AND 20. Personal support is offered in such a way as to promote and protect service users’ privacy, dignity and independence. The systems for the administration of medication are generally well managed protecting service users and ensuring their medication needs are met. However appropriate training of staff regarding the administration of rectal diazepam needs to be implemented. EVIDENCE: Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 17 Information regarding personal care is recorded in the service users plans. This information is recorded on a form called “intimate care guidelines”. There is a recently developed set of guidelines called “ a guide to supporting healthy lifestyles”. This is dated May 2004 and the head of service has attended training on this. The inspector was told that 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 was 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. Service users are encouraged to self-administer their own medication and risk assessments are in place for this. One service user has epilepsy and occasionally requires a rectal stesolid. Staff receive training from The National Society for Epilepsy to do this. A requirement was made following the previous announced inspection that all staff be trained by a suitably qualified healthcare professional and that staff are then deemed competent by a suitably qualified healthcare professional. Staff training was still being undertaken by the National Society for Epilepsy and needs to be undertaken by a district nurse. The inspector looked at a record of current medication kept for each service user. The home uses a monitored dosage system. Unused medication is disposed of via the pharmacy. There are no controlled drugs in use. The heads of service undertake staff training in medication awareness. Medication records for all service users were looked at and it is pleasing to note that there were no omissions. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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): These standards were not assessed during this inspection. EVIDENCE: Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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 and 29 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: Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 20 Each unit contains five flats. The inspector undertook a tour of the premises. Many service users were out at work at the time of the inspection and the inspector did not look in personal bedrooms if the service users were not at home. 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 is a requirement of the report. Flat 48 is nicely decorated, homely, bright and cheerful. It was pleasing to see that the kitchen and worktops have been replaced. The flooring in the bathroom is in a state of disrepair and requires replacing. There is mildew around the edges of the bath and this needs attention. The extractor fan is very loud and the light was flickering. The bathroom in general needs urgent attention and redecorating. Flat 50 was again nicely decorated, homely, bright and cheerful. The kitchen and the kitchen flooring have been replaced and this is pleasing to see. The toilet on the upper floor had been leaking and mildew /mould had developed at the back of the toilet. The leak requires repairing, and action taken to resolve the problem of mildew/mould. This was identified and a requirement made at the previous announced inspection that has not been complied with. This is a requirement of the report. Disco equipment is stored under the stairs and could become hazardous. The flat in general is cluttered due to a lack of storage space. Flat 44 is home to two service users. The kitchen area needs to have its flooring replaced as this is damaged and worn in several places and could be hazardous to service users and staff. This was a requirement of the previous announced inspection and is a requirement of this report. Stains/spills were observed on kitchen cupboards. The enamel at the bottom of the toilet has worn away and is very stained. Despite attempts to resolve this problem it remains very stained and requires replacing. The bathroom in general was in need of a thorough clean. Flat 46 has been refurbished to include a new bedroom. The lounge is very cluttered and during the previous announced inspection it was suggested that attention needs to be given to making the lounge area comfortable and liveable. There is a lack of storage space and this needs to be addressed. The flooring in the kitchen is laminated wood but has been removed from the dustbin area. This needs to be repaired. The kitchen in general was untidy and clean. The flooring in the bathroom is laminated wood and there has been movement in the panels representing a potentially hazardous situation. This needs to be repaired and is a requirement of the report. Generally the flats appear cluttered and could present a risk to service users. It is a requirement of the report that suitable storage facilities are provided for the use of service users. There was a general feeling of un-cleanliness in the flats and it is apparent that service users need further support in this area. This is a requirement of the report. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 21 Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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): 33 and 34 Staffing in the unit remains inadequate, with hours allocated for 52 A Haddon being used at the supported living scheme and the registered manager responsible for two supported living schemes. There are effective recruitment procedures in place to ensure service users are protected from harm, however it is intended that staff files be stored at a central office. This will not make them available at all times for inspection. EVIDENCE: A requirement was made following the previous unannounced inspection that staffing hours allocated for 52 A Haddon are utilised in this unit and not in another establishment. The inspector looked at the staff rotas. These demonstrate that during the month of September approximetely 76 hours allocated for 52A Haddon were used at the two supported living schemes. This is unacceptable and it will again be a requirement of this report. The head of service remains responsible for the two supported living schemes despite two requirements being made following the previous two unannounced inspections. The registered provider has failed to comply with this requirement and the Commission for Social Care Inspection will consider enforcement action if it is not complied with following this report. A random selection of staff files were looked at during the visit. A request was made to look at the file of the most recently employed care worker. The inspector was informed that all documentation for this individual is kept at a Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 23 central office and this is to be the practice of the organisation. Staff records need to available for inspection purposes and it is a requirement of the report that suitable arrangements are made to make certain that personnel records are available for inspection at all times. All remaining staff files contain the necessary details as detailed in standard 34 and schedule 2. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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, 38, 39, 40, 41, 42 and 43. Overall the 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. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The unit do not regularly review aspects of its performance through a programme of self-review and consultations, which include seeking the views of, service users, staff and relatives. The registered manager has a good understanding of the areas in which the unit need to improve. However, the registered manager needs to relinquish responsibility for the supported living schemes so service users may benefit from a well managed service. EVIDENCE: Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 25 The head of service has been employed by MacIntyre Care for 13 years, and has been in post as head of service for approx 5 years. She is presently undertaking her NVQ level 4 training. Examples of further training undertaken by the head of service include epilepsy training, the administration of stesolid training and managing challenging behaviour. Despite staffing shortages and also being responsible for two supported living schemes, the head of service has worked hard to ensure the unit comply with the requirements set at the two previous inspections. Staff understand and can relate to the aims and purposes of the home. This is usually achieved through regular staff meetings, staff supervision and annual appraisals. There is a communications book, handover meetings, service user plans and training. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. Macintyre Care has an equal opportunities policy in place and this was looked at during the inspection. The unit has not undertaken any service user surveys during the last twelve months. Feedback is obtained through flat meetings and link worker meetings. There was evidence that service users were informed about the announced inspection. Regulation 26 reports have not been received regularly from the registered provider, however this has improved over the previous three months. All policies and procedures are kept in the office and are accessible to all staff working in the home. Staff are encouraged to read the homes/organisations policies. There are no policies available in different formats for service users and it is recommended that serious consideration is given to this by the registered provider. If service users wish to look at their own records then this can be facilitated by the home. Records and home records were observed to be up to date, stored securely and in good order. All records seen are constructed, maintained and used in accordance with the Data Protection Act 1998. Fire alarm testing is undertaken weekly and fire drills are carried out with the full involvement of the service users. The home 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. Servicing for gas appliances was due to take place in the following week and the inspector requests that confirmation is sent to the commission when this has been completed. 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. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 26 There are two service users who like to wedge their bedroom doors open and the wedges were observed during a tour of the premises. It is a requirement that a more suitable system is implemented for keeping bedroom doors open. Mandatory training is up to date for all permanent staff. The staff office and sleep in area are small and lack storage space. There are difficulties being experienced with records that need archiving. The head of service has written the units service manager regarding this problem, but to date has received no response. It is recommended that the registered provider give serious consideration to suitable storage facilities for the storage of old/archived records. There are insurance certificates on display in the home. The organisations business and financial plan was not available for inspection. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 X x Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 2 3 2 LIFESTYLES Standard No Score 11 12 13 14 15 16 17 Standard No 31 32 33 34 35 36 Score X X 2 2 X X 3 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Haddon (52A) Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 2 3 DS0000039068.V255730.R01.S.doc Version 5.0 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 6 Regulation 15 Requirement Timescale for action 30/01/06 2 39 12 3 20 13 4 28 23 5 28 23 The registered manager is required to ensure that service users individual care plans 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.(previous timescale of 30/07/2005 not met.) The registered provider is 30/01/06 required to ensure that the views of family, friends and advocates and of stakeholders in the community are sought on how unit is achieving goals for service users. The registered manager is 30/03/06 required to ensure that staff are trained and deemed competent to administer rectal stesolids by a suitably qualified health care professional. The registered provider is 30/03/06 required to ensure that the work tops and kitchen in flat 52 is replaced. (Previous timescale of 30/09/05 not met.) The registered provider is required to ensure that repairs DS0000039068.V255730.R01.S.doc Version 5.0 Haddon (52A) Page 29 6 28 23 7 28 23 8 28 23 9 24 23 10 30 23 11 41 4 12 19 23 identified to the bathroom in flat 48 are completed. This is to include replacement flooring, eliminating mildew, repairing extractor fan and light and redecorating. (Previous timescale of 30/09/2005 not met for replacement flooring.) The registered provider is required to ensure that the problem of mildew/mould to the toilet in flat 50 is resolved. (Previous timescale of 30/03/2005 not met) The registered provider is required to ensure that a) the flooring in the kitchen of flat 46 is repaired around the dustbin area. b) the flooring in the bathroom repaired. The registered provider is required to ensure that a) the kitchen flooring in flat 44 is replaced (Previous timescale of 30/07/2005 not met.) b) the toilet in flat 44 is replaced. The registered provider is required to ensure that suitable storage facilities are provided for the use of service users. The registered provider is required to ensure that service users receive need further support to keep their flats clean and hygienic. The registered provider is required to ensure that suitable arrangements are made to make certain that personnel records are available for inspection at all times. The registered provider is required to ensure that a more suitable system is implemented for keeping bedroom doors open to prevent the use of door wedges. 30/03/06 30/03/06 30/03/06 30/03/06 30/03/06 30/12/05 30/12/05 30/11/05 Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard 1 33 41 Good Practice Recommendations Service users guide to be updated and changes made as necessary. It is recommended that serious consideration needs to be given to increasing the staffing ratios in the unit to allow staff to fully meet the needs of service users. It is recommended that the registered provider gives serious consideration to suitable storage facilities for the storage of old/archived records. Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 31 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 Haddon (52A) DS0000039068.V255730.R01.S.doc Version 5.0 Page 32 - 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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