Inspection on 14/05/08 for Halcyon House

This inspection was carried out on 14th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Halcyon House 17/05/06

Halcyon House 22/12/05

Halcyon House 24/05/05

Halcyon House 02/11/04

Halcyon House 11/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Halcyon House Halcyon Road North Prospect Plymouth Devon PL2 2PJ Lead Inspector Brendan Hannon Unannounced Inspection 14th May 2008 9:30 Halcyon House DS0000003530.V363463.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 Halcyon House DS0000003530.V363463.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. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halcyon House Address Halcyon Road North Prospect Plymouth Devon PL2 2PJ 01752 605541 NO FAX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.mencap.org.uk Royal Mencap Society Mr Terence George Isherwood Care Home 9 Category(ies) of Learning disability (9), Physical disability (9) registration, with number of places Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2006 Brief Description of the Service: The home is located in a single storey purpose built detached building within a row of ordinary semi detached houses in the North Prospect area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicles and the central shopping area of Plymouth is accessible by public transport. The home can accommodate up to nine people. The home is fully accessible to the people that live at the home and visitors who use wheelchairs. The home has one main entrance from which all parts of the home may be accessed. The communal areas of the home are in one half of the building and the residents’ bedroom accommodation is in the other half. There are two communal bathrooms and two communal showers. There is one double bedroom. There are two communal areas in the home. A lounge and dining area and also another lounge accessed through the lounge/ diner. There is a medium sized area of garden and patio to the rear of the building and which is fully accessible. This area can be accessed either round the side of or from the rear of the building. The service offered by the home is for men and women with a learning disability between the ages of 18 and 65. Some of the people that use the service have substantial mobility needs and most have complex needs. The present fees range from a minimum of £415 upward depending on assessed need. The people that presently use the service are of a mixed range of ages and abilities but are in the main active within the home and in the community. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was unannounced. Preparation for the inspection included analysis of the Annual Quality Assurance Questionnaire, the last inspection report and contacts with the home over the last 24 months. An inspection plan was developed from this information. The inspector was in the home from 9.30am to 4.30pm on the 14th May and between 9.30am and 1.00pm on the 15th May. The following inspection methods were used. The inspector spent time with or spoke with most of the people that use the service. The Registered Manager was spoken with at length. Three staff on duty during the inspection were spoken with and personnel files were sampled. The care of three people was case tracked. Care plans, risk assessments, medication records, general records, health and safety records, and staff files were inspected. The whole of the building was inspected. What the service does well: What has improved since the last inspection? Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 6 The management and staff of the service continue to strive to provide the best possible service for the people that live at the home. 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 Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides adequate information about the service to allow a person, with the support of their representatives, to make an informed choice whether to use the service. EVIDENCE: Both the Service Users Guide and the homes Statement Of Purpose were available. The Service User Guide has not been reviewed and therefore inaccuracies will remain. For example, the present complaints procedure is not included, and it is stated that people that use the service have a complete choice of their key worker when at most they will only play a part in the decision. The Guide is available in a simple English and symbol format. The Registered Manager was advised to make further efforts, considering the complex needs of those who use the service, to make information in the Guide still more accessible, perhaps through the use of photographs. However the present Service Users Guide does enable potential new residents, with help from their supporters, to understand the service provided by the home and to make an informed decision as to whether to use it. No one has moved out of, or into, the home for a number of years. There is a pre admission assessment form and procedure available to assess the needs of Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 10 a person who is considering using the service to ensure that the home would be appropriate to meet their needs. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. Peoples’ assessments of care needs, their care planning and individual risk assessments are being maintained appropriately. EVIDENCE: Three peoples’ care plans were sampled. In general they were of good quality enabling the staff to deliver consistent and planned support. Everyone that uses the service had an assessment of their needs, a care plan and risk assessments in place. These were being reviewed approximately every six months. One of the care staff has successfully piloted a new supplementary photographic care plan to make care plan information more accessible. These documents are in addition to the standard Mencap care planning format. Each of the nine people that use the service now has one of these photographic care plans. Due to this work by this support worker the service is commended for its efforts to involve the people that live at Halcyon House in their day to day decision making. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 12 People that use the service should be supported to define both long and short term achievement goals that they can aim to reach with support from the service. Setting goals helps to support peoples’ personal development towards improved skills and also helps them to enjoy a fulfilling lifestyle. A small proportion of people had some general long term goals but these were not well defined nor had dates for review. Regular review of each goal helps to ensure that goals are kept under consideration. Some of the people that use the service have significant moving and handling needs and specific risk assessments are in place to ensure people’s safety. Any restrictions of personal choice or freedoms have been documented to explain why they are in place. These include hard flooring in bedrooms and listening devices to keep specific people safe at night. In general care planning and risk assessment are supporting the delivery of good quality consistent care. Every person has their own bank or building society account. Peoples’ Disability Living Allowance (DLA) mobility element is paid directly into these accounts. The home uses a pence per mile system to invoice each person at the end of every month for their individual use of the homes vehicles. This system is fair and equitable. Each person has an amount of money held individually by the home in their own wallet and then transactions are recorded on individual balance sheets. The people that use the service can be assured that any of their personal money held by the home is being appropriately and safely managed. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people that use the service have enough appropriate activity to ensure a reasonable quality of life while living at the home. There is some inappropriate communication and poor communication/direction amongst the staff and management team. EVIDENCE: There is no clear plan of each person’s regular activities, or list of their preferred potential activities, within their care planning. There was a weekly chart to plan activities for the household but it was unclear and not specific. We witnessed confusion amongst the staff about a planned group activity. This was due to communication difficulties between managers and staff. Direction to staff about the activities they are to undertake is unclear. Each person has a daily diary as well as a significant event record within their care planning file. The sampled diaries and event records showed that there were occasions when no entries were made for a person for a number of Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 14 consecutive days. Also many of the reports made held little information of value. As a result there was no consistent record of the activities and quality of life enjoyed by the people that live at the home. It was agreed with the Registered Manager that in future daily diary entries would be completed at least daily and would record peoples’ activities either within the house or outside. Each persons care plan will list both regular and potential unplanned activities. The homes weekly activity chart is to be specific so that staff are clear about the activities they are to support while they are on duty. Some activities participated in by people when they are out of the home include horse riding, music workshops, adult education and swimming. Within the home ‘make up’ sessions, bingo, and individualised arts and crafts, are supported by the staff. Funding has been agreed to build a sensory room on one end of the building. This development will add to the quality of peoples’ lives. The communal spaces are welcoming. There was a large fish tank in the main lounge and photo boards on the walls in this room. One of these boards showed people that live at the home enjoying their recent holiday. Photographs of the staff presently on duty and coming on duty were displayed in the dining room. During the inspection a member of staff was heard using inappropriate, disrespectful language in regard to and in conversation with more than one person that uses the service. There have been recent disciplinary issues with other members of staff which have involved allegations of inappropriate language while in the company of people that use the service. Inappropriate and unprofessional language was used in sampled daily diary records. A person’s bowel chart was openly displayed on the wall of a communal toilet. The Registered Manager and the Registered Provider must take action to ensure that staff understand what is disrespectful language/communication and that it must not be used. We sat with the people present in the home at lunchtime for their lunchtime meal. The atmosphere was good and the food was plentiful and of good quality. Staff design the menu plan with an awareness of the food likes and dislikes of the people that live at the home. Halcyon House DS0000003530.V363463.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ welfare is maintained by supporting their access to health treatment, adequate administration of medication and by meeting the peoples’ physical personal care needs. EVIDENCE: Everyone present in the home during the course of the days inspection was seen. There was good observable evidence that peoples’ physical personal care needs are being well met by the staff. Evidence from observation, care planning, and discussion with the Registered Manager and care staff demonstrated that care support is provided with care and consideration. Some peoples care files were sampled and these showed that health service input is actively being sought and supported by the home. The people that live at Halcyon House can be assured that their access to health care will be supported and that their physical personal care needs will be well met by the service. In general charts such as recording of epilepsy seizures were being consistently completed. The Registered Manager was advised to ensure that all recording processes that are in use are maintained consistently. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 16 The home mostly uses a monitored dosage system of medication administration. The Medication Administration Record was adequately maintained. Within controlled drug recording, signing for Mydazolam epilepsy medication was carried out effectively. Nearly all the staff have received training to administer this medication safely. Some of the medication blister packs seen in use were in poor condition making loss or damage of the medication more likely. The medication storage room and medication storage cabinets were untidy and the décor of the facility has declined in condition. The medication procedure in place is a national Mencap document and it does not cover all of the areas of medication administration carried out by this service or the specific methods used in this home. For example there is no coverage of the correct handling procedures for Controlled Drugs. A significant medication error took place within the last few months. The reason for this error was that the staff on duty were not clear about who was responsible for the administration of medication during a particular period of time. This system of responsibility has not been changed since the incident occurred. Overall the medication system is operating adequately but areas of operation should be reviewed and improvements made as necessary. One person that lives at the home has developed significant behaviours that challenge the service. These changes and their effects on other people at the home, and the staff, were recognised at the inspection that took place two years ago. Some additional support has been provided by the commissioning authority. However an incident of physical aggression towards staff took place during the inspection. Incident records showed that other people that live at the home and the staff are responding to ongoing physical aggression. During this inspection staff were witnessed not responding skilfully to the episode of aggression. The other people that live at the home occasionally suffer physical aggression from this person. The Registered Manager said that he had supported staff with methods to manage these behaviours appropriately but we did not hear from the staff that they did this in practice. The staff training record showed that only 3 staff have received formal training on working with challenging behaviour. The lack of skill shown by the staff in this area is having a detrimental effect on the individual’s quality of life. These ongoing behaviours continue to put the other people that live at the home at risk of suffering further physical aggression. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Complaints are properly managed by the home protecting the welfare of the people that live there. Those working at the service are aware of their responsibilities regarding protection of vulnerable adults. EVIDENCE: There is a good, accessible complaints procedure displayed in the porch of he home. The Registered Manager said that a more accessible system was being developed by the organisation. Through the advocacy of the Registered Manager and the staff the people that use the service are actively supported to access the complaints procedure. The training records showed that at present only half of the care staff team has received protection of vulnerable adults training, though this training is now a standard training for Mencap staff. The Registered Manager has attended Plymouth City Council adult Protection training for managers. The home has all the appropriate anti abuse policies and procedures in place. Halcyon House DS0000003530.V363463.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): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that use the service benefit from a comfortable, clean and generally well maintained building. EVIDENCE: The building was designed in the 1980s to meet the needs of people with significant mobility needs. However though being built for this purpose it does have the potential to feel quite institutional. The management and staff have made efforts through decoration and fixtures to minimise this potential atmosphere. However boxes of protective gloves had been fixed to the main corridor wall. Such items should be stored out of sight so as to maximise the domestic feel of the home and protect the dignity of the people that use the service. All the bedroom floors now have hard coverings rather than carpet. The management of the service should review whether this is a necessity to maintain each person’s health and welfare. An audible alarm had been fixed to one person’s bedroom door to indicate whenever they left their room. After discussion with the Registered Manager it was clear that there were other Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 19 discrete monitoring methods already in place that made the use of this audible alarm unnecessary and its disuse would better maintain this person’s privacy and dignity. The garden was well maintained for the approaching summer and had garden tables and chairs set out. This private area to the rear of the building was welcoming and domestic. The home was looked at closely during the inspection. Limited damage to doors and skirting boards, due to wheelchair use, was noted. Some alterations have been made to the bathroom in the centre of the home. These changes and the worn appearance of this room have reduced the quality of this facility. Plans should be made to redecorate this room. The other main bathroom and the kitchen were refurbished in 2006. Due the kitchens small size it is inaccessible to wheelchair users during periods of cooking. The home was clean and hygienic. Decoration in the home is generally to an adequate standard. The people that live at the home benefit from an adequately personalised, clean and maintained building to live in. Each bedroom has been decorated and personalised to meet the taste of the person using it. Numerous televisions and music systems were seen in bedrooms and some people have purchased some of their own furniture so that they can enjoy more expensive fixtures. Some people also had various items of sensory equipment, such as a projector and light ball. There are accessible toilets available throughout the home. All toilets and bathroom doors have been fitted with locks that can be overridden from the outside in the event of an emergency. This facility protects both the privacy and the safety of the people that use the service. All the bedroom doors are fitted with a lock. Everyone has been offered the use of an individual key for their bedroom door. Some people are actively using their bedroom door key. Others have chosen not to use a key or their risk assessment has clearly shown that holding a key would create an unreasonable risk for them. The availability of locks supports peoples’ independence and privacy. Halcyon House DS0000003530.V363463.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): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the people that use the service are met by enough competent, qualified, properly checked, and trained staff. EVIDENCE: The Registered Manager stated that there are always enough staff on duty to meet the needs of the people that use the service. The rota record evidenced the usual staffing level. The home has 4 staff in the morning and 3 staff in the afternoon and evening. At night there is one waking night staff and one sleeping in staff. The Registered Managers hours are in addition to this staffing level. There is a cook and cleaner in addition to the care staffing level. The previously stable staff team is now experiencing significant staff turnover. The Registered Manager is aware of the need to maintain consistency of good care practice. Staff training records, personnel files and the Annual Quality Assurance Questionnaire were sampled. Training records showed that basic training was generally up to date. These training areas include First Aid, Moving and Handling and Health and Safety. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 21 Most of the staff team have at least a National Vocational Qualification (NVQ) to level 2 in care delivery. 82 of the care staff team have achieved a relevant qualification in care delivery. A thorough training programme is run by the organisation to ensure that the needs of the people that use the service are fully met by skilled staff. The organisation is training new staff through a new induction programme that includes external teaching days as well as training within the home. This training gives staff specific skills to work with people with a learning disability. This induction training then forms part of an NVQ level 2 and enables staff to meet peoples’ needs soon after beginning work at the home. Personnel records were available in the home to verify the recruitment procedure carried out for each member of staff. These records were sampled and in general the recruitment process had been carried out appropriately. Records showed that Criminal Records Bureau (CRB) checks are in place. A small number of staff had criminal convictions listed on their CRB checks. The organisation had not documented a risk assessment showing that these staff had been assessed as posing no risk to the vulnerable people that live at the home. A programme of six individual staff supervision sessions are carried out per year and this was verified from the supervision record. The Registered Manager carries out these supervisions. This practice helps to monitor staff practice. Halcyon House DS0000003530.V363463.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): 37,38,39,41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is ensuring adequate outcomes for the people that live at Halcyon House. Health and safety is adequately managed by the service. EVIDENCE: The Registered Manager, Terry Isherwood, became the manager for the home in October 2007 and he was registered on 21st January 2008. We were told about various disciplinary issues that have taken place over the past 8 months. We were informed that professional relationships and communication within the staff team are causing difficulties at present. We were informed of leisure activities that did not take place due to these communication difficulties. These problems must be resolved so that the staff Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 23 and management that work at the home cooperate to deliver the best possible support to the people that use the service. The organisation has redeveloped the Quality Assurance system. A quality assurance process is carried out every year. The outcomes from the process carried out in late 2007 have not yet been concluded. When complete the outcomes will be used to inform the next Annual Development Plan. This section covers Health and safety in the home. Comprehensive safety checks have been carried out during the last year, as noted in the Annual Quality Assurance Questionnaire, including gas appliances, and a Legionella assessment. Domestic electrical testing was carried out on 17/04/08 and a new certificate for the electrical safety of the wiring in the building was also seen. All hot water outlets have been fitted with water temperature control valves. Most radiators available to the people that live in the home have been covered or a risk assessment is in place to demonstrate that a cover is not necessary at this time. These measures protect people from the danger of scalds and burns. The latest Plymouth City Environmental Health Department report was seen. We checked the temperature record for the fridges and freezers. These temperatures were appropriate. We were told that the kitchen becomes very hot during the cooking process particularly when a large meal is being prepared, There is limited ventilation in the room from the windows and a small extractor fan. The door to the kitchen is kept closed during periods of cooking for the safety of people that use the service and the staff. We were told that the cooker had not been working recently for a period of a number of days because it had broken down, but that it had now been mended satisfactorily. The accident and incident records had been combined and it was difficult to identify the accident record. There was no means of drying hands in either the main toilet at the end of the building or in the toilet attached to the staff sleeping in room. It is important for infection control purposes that there are full hand washing facilities in toilets and bathrooms. The laundry has both an industrial washing machine and industrial dryer which are appropriate to meet the needs of the people that live at the home. Red laundry bags with soluble seals are used to manage the soiled laundry. Protective equipment was easily available to staff. The laundry was not clean and was untidy. Generally infection control is well managed in the home. Adequate management of health and safety protects the welfare of the people that live at Halcyon House. Halcyon House DS0000003530.V363463.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 2 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 4 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 1 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 1 3 X 2 2 X Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 25 No 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 YA16 Regulation 12(4)a Requirement Staff should only use appropriate language with, and around, people that use the service, so that people are shown respect and their dignity is maintained. The service must enable people that use the service to live without the risk of physical aggression. Staff should be appropriately trained, supported and directed to meet all the needs of the people that live at the care home. The Registered Provider and Registered Manager must ensure that good professional relationships are maintained between staff. Timescale for action 01/08/08 2 YA18 13(6) 01/10/08 3 YA38 12(5)a 01/08/08 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 YA1 Good Practice Recommendations The Service User Guide should be reviewed to ensure that DS0000003530.V363463.R01.S.doc Version 5.2 Page 26 Halcyon House 2 3 YA6 YA14 4 YA20 5 6 7 YA23 YA24 YA34 8 9 10 YA41 YA42 YA42 it is kept accurate. Care planning should include the setting of short and long term achievement goals with review dates. The documentary planning of leisure activities both inside and outside the home should be made comprehensive and detailed. Daily records should reflect the activities each person has participated in both inside and outside the home. The medication procedure should be appropriate to the service, to cover all areas of medication administration carried out by this service, including the Controlled Drug system. It should be clear to the staff on duty which staff member has responsibility for the administration of medication in order to avoid misunderstandings and mistakes. The medication storage room, cabinet and medication blister packs should be clean, tidy and well maintained. All the staff should receive protection of vulnerable adults training. Plans should be made for the redecoration of the central bathroom. Ongoing efforts should be made to avoid institutionalisation in the building. A risk assessment should be documented for any staff member that has previous criminal convictions to show that their fitness to work with vulnerable adults has been assessed. The accident and incident records should be separated to provide a clear record of accidents that have taken place in the home. Ensure there are full hand washing facilities in all bathrooms and toilets. The laundry should be kept clean and tidy to support infection control. The ventilation in the kitchen should be increased for the wellbeing of staff and people that use the service. Reliable appropriate cooking facilities for nine people should be maintained at all times. Halcyon House DS0000003530.V363463.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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