Inspection on 28/06/07 for Haddon House

This inspection was carried out on 28th June 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haddon House 08/06/09

Haddon House 03/11/06

Haddon House 08/12/05

Haddon House 27/06/05

Haddon House 15/03/05

Haddon House 26/10/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Haddon House 145 West Heath Road West Heath Birmingham West Midlands B31 3HD Lead Inspector Sarah Bennett Key Unannounced Inspection 28th June 2007 10:00 Haddon House DS0000016889.V344775.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 House DS0000016889.V344775.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 House DS0000016889.V344775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haddon House Address 145 West Heath Road West Heath Birmingham West Midlands B31 3HD 0121 475 1681 0121 475 1681 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) Haddon House Limited Mr Christopher Higgins, Ms Susan Newton Ms Joanne Tuke Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 3rd November 2006 Brief Description of the Service: Haddon House is a large detached house situated in the West Heath area of Birmingham. It is situated along a service road adjoining the main West Heath Road. The home has six single bedrooms, two of which are on the ground floor and four on the first floor all of which have en-suite facilities. The lounge and dining room are to the rear of the premises. A toilet and shower room are situated on the ground floor. There is a bathroom on the first floor with a grab rail. There is room for parking on the front driveway and access to the house is via sloped wooden decking area, providing wheel chair access. There is a well maintained rear garden that also benefits from a wooden decking area that is covered over. This provides an attractive seating area for service users. A sloping ramp leads to a further small patio area and lawn. There is a range of garden furniture for the service users to use. The home has access to vehicles to transport its residents on occasions, but encourages them to use public transport enabling service users to access local facilities and Birmingham City Centre. Local amenities such as shops, banks and the GP practice are close by and the home has good transport connections via bus and rail services. The home is registered to provide personal care and accommodation to a maximum of six adults who have a mental disorder. The home provides three meals a day and is staffed on a twenty - four hour basis. The Manager said and records showed that the fees charged are between £1200 - £1500 per week. A copy of the latest inspection report is available in the home for visitors who wish to read it. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced fieldwork visit was undertaken by one inspector over one day. This was the homes key inspection for the inspection year 2007 – 2008. Since the last inspection sadly one person had died. There were three people at the home on the day of the inspection as others were visiting their family and friends. The people living there were able to express their views about their life at the home. Care, health and safety and staff records were looked at. A tour of the premises took place. The Manager and the staff on duty were spoken to. Surveys sent by the CSCI to relatives had been returned and their comments are included in this report. What the service does well: The people living there said they liked living there and had a good relationship with the staff. One person said, “I’m very happy here, a lot more confident and staff helped me to feel like this.” The people living there were asked what they wanted to do and where they wanted to go. Staff offered them choice throughout the day and supported them to do the things they wanted to do. Bedrooms are big and decorated in the way that the person chooses. People had a number of personal possessions including pictures and photographs of the people important to them. People are supported to keep in touch with their family and friends so they do not lose relationships that are important to them. One person said, “ The home is brilliant, the staff are ace, it is like a holiday camp.” Care records showed included information on how each person wanted to be supported, the things they like and dislike and what they want to achieve. Staff observed showed awareness of the needs and wishes of each person and supported them in the way they wanted. Relatives said that staff support the people living there to live the life they choose. Specialist support is available from the Community Psychiatric Nurse and Consultant Psychiatrist to ensure that people’s ongoing mental health needs are treated and monitored to ensure their well being. Staff have training so they know how to meet the needs of the people who live there and help them to achieve the things they want. Relatives said that staff have the skills and experience to look after the people living there. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 6 Regular health and safety checks are done to make sure that equipment is well maintained and does not put the people living there at risk of harm. 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 House DS0000016889.V344775.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 House DS0000016889.V344775.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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need so they can make an informed choice about whether or not they want to live there and the home can meet their needs. Each person living there has a contract so they are aware of the terms and conditions of their stay. EVIDENCE: The statement of purpose of the home was last reviewed in January 2007. It included all the relevant and required information so that a prospective service user could make a decision as to whether or not they wanted to live there and the home could meet their needs. There were five people living at the home, one person was staying at her mother’s for a few days and another person was at her boyfriends. Sadly, one person had died since the last inspection. No new people had been admitted. Therefore, the standard relating to assessment was not assessed at this inspection. Each person living there had an individual contract that included the terms and conditions of their stay including the fees they would be charged for living there. It was clear that the contract had been explained to individuals, as they Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 9 were able to say what it was about and what their rights and responsibilities are. Haddon House DS0000016889.V344775.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, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person has a care plan so that staff know how to support them to meet their needs and achieve their goals. People are involved in their care plans and have a choice as to what they do each day. People living there are supported to take risks within a risk assessment framework so to ensure their safety and well being. EVIDENCE: Two records of the people living there were sampled. These included an individual care plan. These stated the likes and dislikes of the person, their physical and mental health needs, dietary requirements, their medication and an assessment as to whether or not they can manage their own, personal care and hygiene, leisure/social, contact with family and friends, psychological support, finances, domestic skills and their cultural and religious needs. Care plans had been regularly reviewed. The review of these was detailed as to how the person’s needs were being met and if they were not being met adequately the care plan was updated. Staff said that if people’s needs change between their CPA (Care Programme Approach) reviews staff at the home look at how Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 11 they can support the person in the interim. They said that the Manager always encourages the person and staff to be involved in their reviews and each person has a monthly review that they are involved in. These are recorded and included talking about how the persons needs are being met and what else can be done to support them including relaxation techniques and alternative therapies and how the person manages their time, which is important in maintaining their well being. They also talk about activities, if they have any concerns or complaints, their finances and look at what they have achieved which helps to improve the person’s self-esteem. Regular meetings with all the people that live there are held and these are recorded. The minutes of these meetings showed that people talk about buying things for the house, students that come on placement there, recycling, having a sports day and a fete, menus, complaints, activities, laundry, tidying their bedrooms and holidays. Each person had individual risk assessments so that staff know how to support the person to minimise the risks in their day-to-day lives. These included their vulnerability, self-injurious behaviour, aggression, violence, mood, relationships, compliance with medication, living skills, physical health needs, personal care, if they are at risk of falling over, their mental health, going to the local shops and ironing. Each person had a risk assessment and relapse management plan. This stated how staff need to support the person to ensure that the risk of their mental health deteriorating is as low as possible and if it does deteriorate staff know how to support the person to manage the risks involved with this. Haddon House DS0000016889.V344775.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, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the people living there experience a meaningful lifestyle. People are offered a healthy diet and can choose what they eat. EVIDENCE: Daily records sampled showed that people go shopping, to parks, to the library, the cinema, go out for lunch, to markets, have barbecues, go bowling, play board games, make cards, go to car boot sales, go to the pub, have therapy and do baking. Three people went with staff to the Lickey Hills for a walk and had lunch out during the inspection. One persons care plan included a plan on how staff are to support the person to be responsible for their daily activity so as to improve their self-esteem and well being. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 13 The Manager said that one person had started going to Warwick Training Centre during the day. Their key worker goes with them to provide support while they are there. Staff said that the company provides two vehicles that people can use to access the community but that staff also encourage people to walk locally e.g. to the shops or GP or to use public transport. People talked about an evening when they went to a line dancing night at Solihull College. They said they bought hats and got dressed up for it. Before they went they had a takeaway meal, had a great evening and got back home late. One person was planning to host an ‘Ann Summers’ party at the home. A student on placement there was helping them to plan it and they went out to deliver invitations to the people living at the other homes that the company owns. One person was planning to go out for a meal for their birthday. They were deciding where they were going to go and who they were going to invite to go with them. Staff were supporting them to make these decisions when they needed it. Most of the people living there went away for a week with staff in May to a villa in Spain that is owned by the company. Records showed and people said that they enjoyed the holiday. Staff said that one person went away with a member of staff to London for the weekend last year. Records showed and people said that they are supported to keep in contact with their family and friends so they do not lose relationships that are important to them. Some people visit their relatives and stay overnight or go out with them to the pub or to a party. The Manager and staff do a home visit to those who spend time staying with their family every three months. They talk about how the visits are going and if any further support is needed while they are there. The Manager said the people living there get on with the neighbours and one person went to the neighbour’s house for a cup of tea in the afternoon. People living there are encouraged to be as independent as possible. Records showed that people help staff to prepare meals, do the food shopping with staff, do their own laundry, tidy their bedrooms, bake cakes and go to the bank. One person said that they have set days when it is their turn to do the washing up and staff support them with this if they need it. Food records and menus sampled showed that a variety of healthy food is offered that reflects the cultural background of the people living there if they choose to have it. Fresh fruit was available that the people living there ate when they wanted it. People are supported to meet their dietary needs where Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 14 appropriate and to follow the advice of the Dietician. People said that they sit with staff in the dining room to eat their main meal so that it is a social occasion. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the personal care and health needs of the people living there are met and they are protected by the management of the medication to ensure their well being. The death of a person living there was handled with respect. EVIDENCE: Care plans sampled showed how the person needed support with their personal care and to meet their health needs. Each person had been assessed for the support they need with moving and handling. This is to ensure that if they do need support to move around this is done in a way that does not put them or the staff supporting them at risk. Records sampled showed that health professionals are involved in the care of individuals as and when this is appropriate. Records showed that the people living there had regular check-ups with the dentist, optician and chiropodist where appropriate. Records sampled included a mood checklist for each person to ensure they have an opportunity to vent their feelings in an appropriate way including talk times with staff about how they are and what they want. This helps the Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 16 person’s feelings to be recognised and alerts staff to signs that the person’s mood may be an indicator of deterioration in their mental health. Staff check people’s weight regularly and keep a record of this. They monitor the records to ensure that the person is not losing or gaining a significant amount of weight that could be an indicator of an underlying health need. One person recently stated that they do not want to be weighed at the home but when they go to the GP surgery or to an appointment with the Dietician. Records showed that staff had respected this and had taken the person’s weight charts out of their file. There was information for staff about the different types of mental illness that the people living there have so that staff know how this may affect the individual. It also provides staff with information on how they can support individuals to be as healthy as possible and cope with the illness they have. One person’s records included a care plan on supporting the person who at times harmed themselves. It included the signs that the person may be likely to do this and what support to give them. Records showed that this behaviour had decreased since the person had been living at the home and had started to learn to control it with relaxation and Reiki exercises. Medication is kept in a locked cabinet. The people living there are assessed as to whether or not they can manage their own medication or what support they might need to achieve this if they want to. If they are not able to do this staff give them their medication. Medication Administration Records (MARS) had been signed appropriately and cross –referenced with the tablets in each pack indicating that medication had been given as prescribed. Some people were prescribed PRN (as required) medication. An individual protocol was in place stating when, why and how much of this should be given to the person. Protocols stated that before medication is given other strategies to help the person should be used e.g. relaxation techniques. They also stated that if the medication is given often then the person’s Doctor should be contacted to review it, as it may not be effective enough. When staff had given a person PRN medication they had recorded in detail on the back of the MARS why to ensure it is given for the right reason and to help the person. At the last inspection a requirement was made that each person should have a protocol that detailed what homely remedies they could take. The Manager said that they had discussed this with their manager and staff and agreed that if a person needs medication that they are not prescribed they would go to the GP for them to make a decision as to what they can take. Each person is prescribed a painkiller PRN so they do not need to go to the GP if they require pain relief. Sadly one person had recently died. The other people living in the home said staff supported them at this time and they could go to the funeral if they wanted to. If they did not want to go this choice was respected. Records of Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 17 meetings of the people living there showed that this had been discussed and people were given a chance to talk about their feelings. Records sampled included the individual’s wishes in the event of them being seriously ill or dying. These included who they would like to make decisions for them, what if any religious preferences they have, how and with whom they would like to spend their last days if they had this opportunity and who they wanted to leave their possessions to. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the views of the people living in the home are listened to and acted on. The people living there are protected from abuse, neglect and self-harm. EVIDENCE: There had been no complaints made to the home or the CSCI in the last year. The Manager said that they get lots of minor concerns raised by the people living there that are recorded in their daily records that are resolved often quickly with staff support but nothing had been raised formally. One persons records sampled showed that they had raised concerns but these had been dealt with appropriately by the Manager and the best outcome achieved to ensure the individual’s well being. The complaints procedure was available to the people living there and they said they knew how to make a complaint if they were unhappy about anything. Relatives said that they know how to make a complaint if they need to and that if they have raised a concern it had been responded to appropriately. Training records showed that staff had received training in adult protection and the prevention of abuse and in the Mental Capacity Act so they know how to ensure people are protected and their rights are respected. Where there had been concerns about the protection of the people living there the Manager said and records showed that the person’s social worker was involved in any decisions made about their welfare. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 19 Daily records were descriptive about individual’s behaviour and non judgemental showing that staff respect the individual and recognise that their behaviour is often a symptom of their illness. Where people had indicated that they were going to harm themselves records showed that staff supported the person and when necessary sought the support of health professionals. People said that they are supported to manage their own money and care plans were in place stating the support that staff are to give. This included help with budgeting and supporting people to go to the bank. They are provided with a safe place to keep their money. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are generally sufficient to ensure that people live in a homely, clean, comfortable and safe environment. EVIDENCE: On the ground floor there were two bedrooms, a laundry room, kitchen, dining room, WC for staff, lounge and office. The sofas were split and worn in the lounge. The Manager said that they are waiting for a new one to be provided and also the lounge is to be redecorated. The wallpaper had not been changed since the home opened. It looked worn and behind the radiator was coming off the wall. It had been stuck back on to try to make the room look comfortable but this room now needed urgent redecoration. People’s bedrooms that were seen were well decorated and furnished in the way that they wanted them to be. People said that if they wanted to they could buy their own furniture if they wanted to. There were photographs of people important to them and pictures that reflected their interests around people’s rooms. Some people have their own fridge in their bedroom where they can keep drinks and snacks that they can have when they want them. The vacant Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 21 bedroom was going to be redecorated and the Manager said that new furniture was going to be provided in this room. Each person has an en suite shower and toilet. There is a shared bathroom upstairs so that people can have a bath if they want to. At the rear of the home there is decking that leads to the garden. This is covered and seating is provided and people were observed spending time sitting there and having a drink or snack. A barbecue is provided and the people living there said this is used and they enjoy having a barbecue. The home was clean and free from offensive odours throughout. Staff do the cleaning but the people living there are involved in this and are encouraged to keep their bedrooms clean and tidy. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements ensure that the people living there are supported by a trained, supported and supervised staff team who can meet their individual needs. The people living there are protected by the home’s recruitment practices to ensure their safety and well being. EVIDENCE: Staff records sampled showed that staff had completed or were undertaking NVQ level 2 or 3 in Care. The Manager said and rotas showed that there is usually two or three staff on during the day. However, when the vacancy is filled and there are six people living there, there would always be three staff on duty. At night there is one waking night and one sleep-in staff. The Deputy Manager is on maternity leave. Bank staff are used to cover vacancies. The Manager is supernumerary to the rota. The Manager said there are usually one or two social work students from a local university on placement at the home and they are also supernumerary to the rota. Staff meeting minutes showed that these are generally held monthly. Staff talked about taking the people living there on holiday, use of mobile phones, Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 23 household chores, activities, offering choice, transport, support to be offered to individuals, menus and mealtimes, petty cash and social work students. The Manager said that all staff are expected to attend at least three staff meetings a year so that they know what is expected of them in their job role and how to meet the needs of the people living there. Three staff records were sampled. These included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken to ensure that suitable people are employed to work with the people living there. The Manager said that there is not a budget for training so where possible they access free training to ensure staff have the training they need to meet individuals needs. Records sampled showed that staff had received training in fire safety, food hygiene, communication, moving and handling, diabetes, anxiety and depression, adult protection and the prevention of abuse, dementia, Safe Handling of Medication, Drugs Awareness, first aid and the Mental Capacity Act. Records showed that when staff started working at the home they had an induction so they were clear of their job role and how to meet the needs of the people living there. One member of staff who started this year was completing the Birmingham Care Development Agency (BCDA) Induction Workbook for Adult Social Care Workers. This was comprehensive and they were doing this in addition to the induction provided by the company. Staff records showed that staff had regular, recorded supervision sessions with their manager. Records of these showed that the training and development needs of individuals were identified and any poor performance was identified and monitored at subsequent sessions. Records showed that staff had not had appraisals annually. The Manager said that things are generally dealt with in supervisions but are not always formalised into appraisals. For each member of staff there was an individual risk assessment that stated any risks to them, the people living there or other staff. These were regularly reviewed and updated if there were any changes. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live there benefit from a well run home that ensures their health, safety and welfare are promoted and protected. Arrangements ensure that the views of the people living there underpin all self-monitoring, review and development by the home. EVIDENCE: The Registered Manager is trained in nursing people who have a learning disability (RNLD) and is also trained to work with people who have mental ill health. They completed their NVQ level 4 and Registered Managers Award in 2006. The owner visits the home monthly and writes a report of their visit as required under Regulation 26. These reports showed that the views of the people living there had been asked for. People living there had also completed Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 25 ‘Comment Cards’ that asked for their views about the home. There is also a monthly maintenance audit to ensure that the home is maintained and decorated so that it is comfortable and safe for the people who live there. The fire procedure was produced using pictures making it easier to understand and was displayed in the dining room. Regular fire drills are held. This ensures that the people who live there know what to do if there was a fire. Staff test the fire equipment regularly to make sure it is working. A fire officer completed a fire safety audit in November last year. They recommended that the cupboard under the stairs should be locked and a smoke detector needed to be installed in the loft. Records showed and the Manager said that these had been done to ensure the safety of the people living there. An engineer regularly services the fire equipment to make sure it is working and well maintained. A Corgi registered engineer completed the annual test of the gas equipment in September 2006 and stated that it was safe to use. An electrician completed the annual test of the portable electrical appliances in January this year to make sure they are safe to use. An electrician completed the five yearly test of the electrical wiring in February 2006 and stated that it was in a satisfactory condition. Staff test the water temperatures weekly to make sure they are not too hot or cold, which could put the people living there at risk of harm. Staff test the fridge and freezer temperatures each day and keep a record of these. They showed that they are within the safe limits for safe food storage to ensure that the people living there are not at risk of food poisoning. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 (2) Requirement The lounge must be redecorated and refurnished to ensure it is homely and comfortable for the people living there. Timescale for action 31/08/07 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. Refer to Standard YA36 Good Practice Recommendations Staff should have a formal annual appraisal to ensure that their performance is being monitored so that they are able to continue to meet the needs of the people living there. Haddon House DS0000016889.V344775.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 House DS0000016889.V344775.R01.S.doc Version 5.2 Page 29 - 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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