Inspection on 24/07/06 for Halliday Square, 57

This inspection was carried out on 24th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Halliday Square, 57 24/05/07

Halliday Square, 57 27/11/06

Halliday Square, 57 30/12/05

Halliday Square, 57 09/08/05

Halliday Square, 57 16/08/04

Halliday Square, 57 14/04/04

Halliday Square, 57 10/10/03

Halliday Square, 57 12/05/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Halliday Square, 57 Windmill Park Estate Southall Middlesex UB2 4UQ Lead Inspector Ms Jane Collisson Key Unannounced Inspection 24th July 2006 10:00 Halliday Square, 57 DS0000027708.V300125.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 Halliday Square, 57 DS0000027708.V300125.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. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halliday Square, 57 Address Windmill Park Estate Southall Middlesex UB2 4UQ 0208 813 8222 0208 813 8228 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) Vanessahalfacre@nas.org.uk National Autistic Society Mr Gideon Attram Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: 57 Halliday Square is a home for six service users with autistic spectrum disorders. The National Autistic Society manages the service and Notting Hill Housing Trust owns the premises. The home is an end-of terrace, three-storey house, located on a housing estate close to Ealing Hospital, and is purpose built. There are two local shops on the estate but the centres of West Ealing, Ealing Broadway and Southall can be reached by public transport from the nearby Uxbridge Road. The communal facilities consist of a lounge, dining room and a kitchen on the ground floor, and a lounge/activity room on the second floor. There is a small garden to the rear of the property and private parking to the front. All of the bedrooms are single, with one located on the ground floor and five on the first floor. Each has its own wash hand basin. There are three bathrooms with toilets, one on each floor, and an additional toilet. Changes were being made at the last inspection to change the ground floor office into a bedroom for a service user with poor mobility and relocate the office to the second floor. This work is now complete. The former first floor bedroom is now the staff sleeping in room. The home has a Registered Manager, registered in 2006, who also manages Golden Manor, a care home for two service users. This is located about one mile away. Both homes share the same staff team comprises of the Registered Manager, one Senior Coordinator, who has responsibility for Golden Manor, three senior support workers, a team of day and night support workers, and an administrator. At Halliday Square, there is a minimum of two staff on the early shift and three on the late shift, a waking night staff and a member of staff sleeping in. Golden Manor has single staff cover only. The staff provide support with personal care, practical tasks and activities. Most service users attend the National Autistic Society day services. The home has its own seven-seater transport. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced on the 24th July at 10.10am. The Registered Manager was present, together with two of the staff team and three service users. One service user was on holiday with family members. One of the service users from Golden Manor, the home that is managed and staffed by the Halliday Square team, was also present. At the end of the visit, the Registered Manager went with the Inspector to commence an inspection of Golden Manor and provide access, as the staff and service users are sometimes out. An additional visit was made to Halliday Square on the 8th August to meet other service users and staff, and examine the records, including those which are held jointly for the two homes. Four service users were present, together with four staff. The Registered Manager was on extended annual leave until early September. Although most service users usually attend the National Autistic Society day services, which are located in Acton, a two week summer break was taking place. Between the visits to Halliday Square, three of the service users went on holiday with staff to Hastings and another went away with relatives. Two service users chose not to go away, one preferring a number of day trips to museums and galleries. The changes in the home that were being undertaken at the last inspection have been completed and one service user now has a bedroom on the ground floor. The work on the second floor was also complete and the office is now fully functional. The lounge on the second floor now has sensory equipment to provide a relaxing area for the service users to enjoy. The garden was being maintained by a staff member and provides a pleasant area for the service to enjoy in the good weather. The second Senior Co-ordinator had recently left the employment of the National Autistic Society and it had been decided not to fill the post as there are changes planned for the Golden Manor service. There is now one Senior Co-ordinator, with specific responsibility for that service. Since the last inspection, the manager has completed his registration with the Commission for Social Care Inspection. Twenty two requirements were made at the last inspection. That inspection followed a long period without a Registered Manager in post and a number of staff vacancies. Although the situation has improved, and efforts have been made to meet all of the requirements, six requirements have been repeated as not met, or fully met. A further nine requirements have been made. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The complaints procedure needs to be amended to ensure that the service users and their families are aware of the role of the Commission for Social Care Inspection and to meet the Care Home Regulations 2001. The amended procedure needs to be included in the Statement of Purpose and Service Users Guide to ensure that they have access to the information. Service users and their representatives should be fully aware of all of the fees, facilities and services available by ensuring that terms and conditions are provided and updated as required. While there are service users’ care plans in place, the files contain excessive and sometimes out-of-date information, which makes it difficult that which is current. Although a new care planning system is being prepared nationally, the information held needs to be streamlined for ease of use, particularly to aid new staff. Service users and their representatives need to be shown to have been involved in the care planning process wherever possible. Further monitoring of service users health files are also required to ensure that all of the outcomes are fully documented and can demonstrate that appropriate action has been taken. The risk assessment information is variable in quality and needs to be recorded in a standard format for ease of use. Where service users’ behaviour is causing difficulties, there needs to be clear guidance on how staff deal with the behaviour. There was found to be no stock control system for medication being given to a service user going on holiday and for checking it upon return. Another medication had been changed, but there was no recording about the authorisation of this. The Registered Manager must ensure that regular monitoring of the medication is undertaken and that staff are made aware of their responsibilities in relation to medication administration. While improvements have been made to the financial procedures, following requirements at the last inspection, there was still found to be some shortfalls Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 7 in keeping receipts. A robust monitoring system is required to ensure that all receipts are kept when staff are responsible for service users’ finances. Several dining chairs had been broken, leaving only two chairs for six service users. Staff were uncertain if new chairs had been ordered and the home needs to have systems which would support staff to find information. For staff to be supported, a previous requirement was made for regular one-toone supervision to take place. From the records seen, the National Minimum Standard, of having a minimum of six sessions a year, is not being met. The Registered Manager needs to ensure that, where this task is delegated, senior staff are providing this support and there are systems in place to evidence this. Although the National Autistic Society undertakes an annual accreditation exercise, this does not fulfil a review of the quality of care, which involves service user consultation and demonstrates how the home intends to develop and improve. This has been an outstanding requirement and needs to be addressed. Some record keeping was found to have improved, but there is a need for the service users’ care planning, risk assessments and guidance to be easier to use and up-to-date. Maintenance records were easier to access, but the frequency of the servicing and testing of equipment needs to be shown to be sufficient to meet the health and safety standards for the home. The fire records did not demonstrate that all of the staff had attended fire drills. Evidence is required to be produced to show that all of the staff are fully conversant with the fire procedures and the guidance of the London Fire and Emergency Planning Authority is being met. 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. Halliday Square, 57 DS0000027708.V300125.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 Halliday Square, 57 DS0000027708.V300125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Documentation is available to provide service users and their representatives with most of the information they require about the home. However, the completed terms, conditions and fees were not available for inspection and this is an outstanding requirement. As there are no vacancies, the referral and admission procedures could not be fully assessed but are in place should they be required. EVIDENCE: The Registered Manager has revised the Statement of Purpose and Service Users’ Guide, which cover both the Halliday Square and the Golden Manor services. To support service users to understand the information, the Service Users Guide is provided in a visual format. Previous plans to have the Service Users Guide in a wider variety of formats, which would suit the various communication needs of the service users, have not been progressed. It is recommended that, where service users would find other visual formats easier, these are used to promote better understanding. The information on complaints in the Service Users Guide and Statement of Purpose needs to include information on the Commission for Social Care Inspection, as required under the Care Home Regulations 2001, should service users or representatives require this information. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 10 As there are no vacancies in the home, and no new service users have been admitted for some time, the assessment procedures could not examined. The systems are in place, however, should any new service users be admitted, which would include an assessment by the National Autistic Society. The terms and conditions have not been completed. This is an outstanding requirement and it needs to be shown that the service users and their representatives have the information regarding fees, payments and services, on an individual basis. Halliday Square, 57 DS0000027708.V300125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system is in need of streamlining as the current information does not aid the continuity of service users’ care and support. The risk assessments also need to be improved so that it can be seen that all of the risks have been minimised and action taken when circumstances change. A standard system would help to make the information more accessible. EVIDENCE: Three of the service users’ care plans, which are stored in the second floor office, were examined and all contained some up-to-date care planning information. However, a large amount of information is held in the files, some of which was found to be out-of-date and some was up to four years old. This does not assist staff to use the current care planning information or provide good continuity, showing the outcomes of planning. Further information is kept in the dining room, including details of medical visits. Some of this information is duplicated and it was found to be difficult to follow through the progress of the short terms and long term goals which have been identified. A monthly update is written by the service users’ key Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 12 worker, some being stored separately to the main files. One annual review was still to be held, but the other files contained details of recent reviews. Lengthy assessment systems are used but it could not be seen how the information was informing the care planning system. The Registered Manager agreed that, while much of the information is completed as required, it is not always used for any meaningful purpose. He said that the National Autistic Society intends to produce a new care planning system. It is recommended, in the meantime, that the information which is currently in use, and relevant to the service users’ support, is put into better order. The systems used in different parts of the home need to be amalgamated to ensure that the information is used to provide a good continuity of care. It should be shown that where the service users are able to participate in their own care planning, they are enabled to do so. Service users are generally encouraged to make decisions about their daily activities and staff were seen to support them with this. This included making choices about being in communal areas, staying in their bedrooms or going out shopping. One service user chooses not to attend any day activities and did not wish to participate in any holidays, although the Registered Manager said that he has been encouraged to do so and is regularly offered opportunities for outings and day services. An annual consultation is held, using external verifiers, which includes consultation with the service users. The staff said that this year’s had been completed in June but the report is not yet available. Service users were seen to be consulted about daily activities and had chosen whether or not to go on holiday. Staff were seen to conversing with the service users in ways which took into account their individual communication needs and preferences. Some of the service users use communication boards, with symbols, to support them to know how their day is planned. A variety of risk assessments were seen in the files examined and there is more than one style. Some are out of date and the current working files should contain only those that are now relevant. Not all staff had signed the risk assessments, which is the system used to ensure that staff are fully aware of any hazards. The record of incidents and accidents was examined. There were a high number of incidents for two of the service users, many of which involved verbal aggression. The records do not demonstrate fully how some of these service users are being assisted to manage their behaviour. However, one incident was observed which was dealt with calmly and effectively during the inspection. One service user was noted to be seeing a psychologist on a weekly basis. Some of the behaviour of the service users was shown to impact on the other service users. Better recording of the cause and effect of the incidents is required to show if these incidents can be minimised, with additional professional help being seen to be accessed when required. Where they impact on other service users, it must be shown that careful monitoring and reporting are promoting their interests. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 13 Because the office is now on the top floor, the information for daily use is still kept on the ground floor dining room where it was seen to be used by the staff and was left where it could be accessed by visitors or other service users. The office on the top floor has a good deal of storage and confidential files are in lockable cupboards. It is recommended that limited records are kept in the dining room to ensure that confidentiality is maintained. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are shown to have the opportunities to participate in day services, leisure activities and annual holidays. Family links are maintained and encouraged. EVIDENCE: Five of the service users have regular programmes which include visits to the National Autistic Society day services, located in Acton, for people with autism. It is planned that a new service, specifically for service users with Asperger’s syndrome, will be open later in the year. It is intended that one of the service users will transfer to the service. The home is located on a housing estate close to the Uxbridge Road and close to Ealing Hospital. There are two general stores within the estate which are accessed by the service users on a regular basis. Although there are no other amenities nearby, bus routes to all the main shopping areas are within walking distance and the home has its own seven-seater transport. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 15 Those service users who have families are enabled to maintain regular contact and several service users go on holiday and outings with family members on a regular basis, quite often abroad. One service user went away with family members during the inspection although was met briefly during the first visit. Three of the service users went for a week to Hastings, between the two visits, and another service user chose to make a series of day trips in London to museums and art galleries. The sixth service user was offered the option of a holiday or trips but did not choose to participate in either. The service users who were able to do so, indicated that the holidays had been enjoyed. Staff said that the service users going to Hastings had enjoyed the beach and shops, and the additional exercise. It was hoped to try and maintain a good exercise regime as it was obviously of great benefit. One service user was very pleased to show all the items that had been purchased whilst away. Service users are supported to maintain the routines they prefer by the staff team. The home has a fairly relaxed atmosphere but observation took place of the some service users having to be reminded about their obligations towards other service users, staff and visitors. Service users are supported to know about the main meal for the day by information being displayed in the dining room, together with names of the service users who are assisting with the preparation. A food diary is kept to record the meals provided to individual service users. The service users come from diverse ethnic backgrounds. Their cultural needs are detailed in their care plans and their wishes, with regards to religious observance, are recorded. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health care records require improvement to show that the health needs of the service users are fully documented and the outcomes of professional support are recorded. Better monitoring of the medication systems is required to ensure that staff are following good administrative procedures. EVIDENCE: There are sufficient bathroom facilities, together with wash basins in the bedrooms, for the service users to have personal support privately and to have the facilities to suit their individual needs. The gender mix of service users, three male and three female, is reflected in the staff team to enable same gender care to be provided. Some improvements are required to the service users’ files so that the information on health needs is kept in a way which demonstrates that all of their needs are being met and outcomes can be clearly identified. Information is kept in separate files, in different areas of the home, and this does not assist in showing how health needs are being followed through. It is recommended that the information on health and medical needs are Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 17 maintained in a way which demonstrates that each area of support, such as regular tests, hospital visits and dentistry, is fully documented and the progress and outcomes can be clearly recorded. One service user is able to self-inject insulin but the guidelines on supporting the service users need to be updated and produced in a clearer format. It was not possible to see the regularity required for monitoring and the outcome of this from the records available. There were a number of requirements regarding medication at the previous inspection. The Registered Manager confirmed that the practice of the double dispensing medication, into dosette boxes, had ceased and that staff have now been trained by a pharmacist. However, at this inspection, further poor practice was found. The medication for a service user, who had been on holiday with relatives, was not recorded when going away or on return. The stock of medication could not be confirmed. One of the tablets had not been available, so another tablet had been substituted. Although the staff member said that this had been approved, there was no recording of this. The Registered Manager must ensure that staff are aware of the necessity to account for all medication and record any changes which occur, and who authorises them. Staff confirmed that they had taken the full blister packs of the medication required on the recent holiday. The service users are all in a younger age group. As the disabilities of the service users may make death, or serious illness, difficult issues to discuss with them directly, the wishes of their families have been recorded in care plans where this has been ascertained. Halliday Square, 57 DS0000027708.V300125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The National Autistic Society complaints procedure is in need of amendment and those in the home’s documentation need to show information about the Commission for Social Care Inspection. No complaints have been made at Halliday Square but work could be carried with the service users to ensure that any difficulties they have with other service users are recorded and addressed. Although financial procedures have improved, not all were being followed and robust monitoring is required to safeguard service users’ finances. EVIDENCE: The records indicated that there have been no complaints made since the last inspection at Halliday Square although, in the jointly held file, two were recorded by the service users at Golden Manor. The National Autistic Society complaints procedure was found to be very lengthy and would benefit from being more succinct. There are simplified versions in the Service Users Guide, which has some symbols, and Statement of Purpose. Details of the Commission for Social Care Inspection are not contained in any of the versions and references to the National Care Standards Commission need to be removed so that there is no confusion should the CSCI need to be contacted. The disabilities of the service users may make the process of complaining more difficult, but there were incidents seen to be recorded where service users may have been unhappy at the behaviour of other service users. The staff should look at how these issues can be recorded and support given to resolve any conflicts. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 19 There have been no adult protection issues in the home. Not all of the staff had undertaken training in adult protection at the last inspection but the current records provided showed that all those on the current rota had attended training in adult protection, apart from the staff member only recently recruited. It was a requirement that the procedures in place to manage the service users’ finances must be improved to include procedures for the monitoring of records, recording and keeping of receipts, storage of cash, and amount of cash held. New systems had only recently been put in place and bound books are now being used for each individual service user, rather than loose leaf sheets. Money is being stored in two areas of the home and the Registered Manager needs to ensure that there are systems in place, regularly monitored, to record the money being moved between the two safes. The service users’ personal allowances are received from the National Autistic Society, weekly or fortnightly, and paid into the service user’s individual accounts. An examination of a sample of the books showed that not all of the items purchased had receipts. In order to safeguard the service users, staff must ensure that, where they are involved in transactions, the receipts are retained and all of the money can be fully account for. Receipt books were to be purchased to record items where no receipts are available and to show who had the responsibility of handling the money. The National Autistic Society had recently carried out a financial audit but the report had not yet been received. Halliday Square, 57 DS0000027708.V300125.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 at least once during a 12 month period. 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 home has sufficient communal space for the service users to have a choice about where they spend time. One lounge has been provided with additional equipment to support service users to relax. The bedrooms seen were satisfactory for the lifestyles of the service users. The work on the bathrooms has been carried out as required but one shower needs to be replaced to provide more efficient equipment. When new furniture is purchased, it needs to be sufficiently robust to withstand the amount of wear and tear it receives. EVIDENCE: The premises provide a pleasant, airy and bright environment for the six service users. With the change over of bedrooms, to provide ground floor accommodation for a service user with mobility problems, there was a loss of some communal space but the areas now provided appear to be sufficient for the needs of the service users. The second floor lounge has been tidied and has sensory equipment to provide a relaxing atmosphere. On second visit to the home, only two chairs were in the dining area. Staff said that the others had been damaged, over time, by one of the service Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 21 users. The staff said that, as far as they were aware, the chairs were on order. There were window seats available, off the kitchen, for temporary seating and also garden chairs which could be used. The Registered Manager needs to ensure that the furniture supplied is sufficiently robust, particularly in areas used by up to nine service users and staff throughout the day. Two of the bedrooms were shown to the Inspector of this inspection. Both service users indicated that the rooms suited their needs. One service users had a television and stereo. The other service user showed a number of items brought during the recent holiday and well as a wide range of other personal belongings. The carpet in one bedroom had been recently replaced but the other was stained and in need of cleaning or replacing. One service user’s bedroom has been relocated to the ground floor to accommodate mobility problems. The room was seen at the last inspection and provides suitable accommodation. Although there is a shower room and toilet close by, the service user is, at times, able to access the facilities on other floors. Improvements have been made, as required, to the fabric of the bathrooms including the removal of mould. One shower, in the top floor bathroom, needs to be replaced as there is insufficient water pressure. This needs to be carried out within a reasonable timescale. The dining room is a well used area, by service users and by staff, who have files stored in the room and use it for recording. The small garden, with flower tubs, is well maintained by a staff member and provides a pleasant area for the service users to use. A part-time cleaner is employed and the home was seen to be clean and tidy on this inspection. There is a separate laundry room on the ground floor. Halliday Square, 57 DS0000027708.V300125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have most of the training in basic courses and autism to support them with the work in the home. The target of having 50 of the staff trained to National Vocational Qualification Level 2 has not been met but staff are progressing towards this. Training and recruitment record keeping has improved but the Registered Manager needs to ensure that good recruitment practice, such as confirming references, is maintained. EVIDENCE: The staff team vacancies were in the process of being filled and this should provide more continuity for the service users. There is a bank of staff who cover for leave and sickness but most of the staff met during the course of this inspection were permanent. The second Senior Coordinator left recently and it has been decided that the post will not be filled. The remaining Senior Coordinator has responsibility for the Golden Manor home as well as working at Halliday Square. The Registered Manager said that the team has three Senior Support Workers, two full-time and one part-time, which should be sufficient supervisory cover. The future of the Golden Manor home was uncertain at the time of this inspection and the staffing situation will need to be reviewed when the outcome of this is known. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 23 Information provided showed that the staff team have undertaken all of the basic training and most have undertaken the National Autistic Society specific training on the communication systems, TEACCH and SPELL, which support them to work with service users with autism. It was seen that most have Asperger’s awareness training. Individual records were provided but it is recommended that the schedule previously in use is maintained. This had easily accessible information as to when training was completed and when it is required to be updated. The three staff records examined included one for a newer member of staff, who was undertaking induction. These were found to be mainly in order and the record keeping for recruitment and training has improved to assist the process of finding information. However, some of the references obtained did not have the dates of employment. The administrative officer, who is involved in the recruitment procedures, undertook to ensure that the information is sought in future. The original Criminal Records Bureau disclosures were not seen but the details and dates of obtaining were available. Although the Registered Manager had delegated staff to undertake supervision, an examination of the records showed that staff supervision sessions would not meet the National Minimum Standard of a minimum of six sessions a year. This has been a previous requirement and it needs to be demonstrated that staff are supported with their work, particularly when key working with service users, and have the opportunity to discuss their training and development needs. The Registered Manager was advised to carry out regular monitoring where supervision is delegated to other staff and recommended to keep information, on a schedule, to demonstrate that all of the staff have the required support. At the last inspection, the home had not met the target of having 50 of the staff trained to National Vocational Qualifications Level 2 or above. The Registered Manager provided information on the status of NVQ training in the home. This showed that two staff had almost completed the qualification, and all but those recently recruited were undertaking the qualification. The three staff who had finished their probationary period were due to enrol. Halliday Square, 57 DS0000027708.V300125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A large number of requirements were made at the inspection in December 2005 when the new manager had just commenced work. The home had been without a Registered Manager since 2004 and acting staff provided cover. There had not been a full staff team. This situation has improved and staff who were spoken to said that they felt the home was now more settled. The manager has now been registered with Commission for Social Care Inspection and an almost complete staff team has been recruited. There was some uncertainty over the future of Golden Manor at the time of this inspection, which may impact on the number of staff required. The Registered Manager has NVQ Level 3, NVQ Level 4 in Care and the Registered Managers Award and had previous experience as the manager of a care home. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 25 The annual autism accreditation had been carried out in June 2006 although no report was yet available. A copy of the 2005 report was provided which showed that relatives’ views had been sought. Halliday Square and Golden Manor are inspected jointly for the purposes of the accreditation. The audit does not fulfil the requirement for a review of the quality of care, which should look at improving and developing services. This remains an outstanding requirement. As the two homes provide quite different services, it would be more relevant to have a separate review of each of them. Monthly visits are made, under Regulation 26 of the Care Home Regulations 2001, and reports have been provided to the Commission for Social Care Inspection. These do not always have sufficient information to show which records have been checked in detail and would not necessarily indicate to staff where there are shortfalls. While record keeping has improved in some areas, much of the information held needs to be streamlined. Although the majority of the maintenance records were available for inspection, some of the servicing appeared to be overdue. This included a check on the emergency lighting. Clear guidance regarding frequencies of servicing and testing, and monitoring systems to check that these are completed, would support staff to ensure that all of the health and safety requirements are met. When the London Fire and Emergency Planning Authority officer visited in March 06, he found the fire precautions satisfactory except for the location of the photocopier and recommended that it be moved as it is housed under a staircase. This had not yet been done as a new, smaller photocopier is to be purchased and will be moved to the second floor when obtained. It was noted that the fire drill records do not show who was present and there is no monitoring to ensure that all of the staff have participated in regular drills. This needs to be carried out to demonstrate that all staff are fully aware of the procedures and they have knowledge of how they would support the service users, particularly at night, in the event of a fire. The London Fire and Emergency Planning Authority guidance is for two drills to be carried out for day staff and four for night staff annually. The fire alarm was last serviced in June 2006 and the fire extinguishers had their annual check in January 2006. Other records showed that the Landlord’s Gas check was carried out in May 2006 and the small electrical appliance tested in June 2006. The Legionella testing had not been carried out since October 2003 and the electrical wiring tests, last carried out in 1999, appeared to be overdue. The Registered Manager said that a schedule of testing has been provided by the landlords, the Notting Hill Housing Trust. The Registered Providers must ensure that the frequency of maintenance and testing meets the health and safety standards required for the home. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 26 As part of the quality monitoring procedures, a system should be introduced which clarifies the type and frequency of servicing required for all of the equipment used and training to be undertaken by staff. It was not shown that staff were fully conversant with the need for health and safety monitoring, as refrigerator temperatures were being recorded as being too high, both in the domestic refrigerator and the medication refrigerator without action apparently being taken. The water temperatures records were seen to be satisfactory and were now being taken monthly. There is no moving and handling equipment, or a lift, to be serviced. Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 2 X 2 2 X Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation Requirement Timescale for action 31/10/06 2 YA5 3 YA6 4 YA9 5 YA19 4(1)c, 5(1)e, The Statement of Purpose and 22 Service Users Guide must be amended to include the required information on the complaints procedures. 5(1)(b)(c) The National Autistic Society 17(2)(8) must provide the contract/terms and conditions to the service users. (The previous timescale of 31/03/06 not met). 12 (1) (a), The care planning systems must 15 (1) be up-to-date, produced in formats which support the health and welfare of the service users to be promoted, and be shown to include the service users, or their representatives, in the process. 13(4) The risk assessments must be 17(1)(3)(a) updated and completed in a format which provide staff with the information to minimise any risks to the service users. 12 (1)(a)(b) Further monitoring of service users files is required to ensure that all of the outcomes of health issues are fully documented and to show that action has been taken appropriately. (Previous DS0000027708.V300125.R01.S.doc 30/11/06 30/11/06 31/10/06 31/10/06 Halliday Square, 57 Version 5.2 Page 29 6 YA20 12 (1) (a) 13 (2) 7 YA20 13 (2) 8 YA22 22 (3) & (7) 9 YA23 13 (6) 10 YA24 23 (2)(b) 11 YA36 18 (2) 12 YA39 24 13 YA41 17 (1)(2) timescale of 28/02/06 not fully met. The Registered Manager must ensure that staff are aware their responsibilities to record when any changes are made to a service user’s medication and provide evidence of why this has been carried out. The Registered Manager must ensure that staff are following the administration procedures in respect of the medication in stock. Monitoring must take place to ensure that recording is taking place when stock leaves the home and is returned. The information in the complaints policies must contain details of the Commission for Social Care Inspection and how it can be contacted. (Previous timescale of 31/03/06 not met). The systems must be in place for staff to ensure that all of the items purchased for service users are receipted and evidence that the systems are monitored must be introduced. Sufficient furniture, of an suitably robust quality, must be provided in the home for service users to be seated at the dining table. Regular one-to-one supervision of staff must be undertaken. (The previous timescale of 31/03/06 not met) A review of the quality of care, together with improvements to be made, must be undertaken at regular intervals and include consultation with the service users. (The previous timescale of 30/04/06 not met) The record keeping in the home must be improved to ensure DS0000027708.V300125.R01.S.doc 15/09/06 15/09/06 31/10/06 15/09/06 30/09/06 31/10/06 30/11/06 30/11/06 Page 30 Halliday Square, 57 Version 5.2 14 YA42 13 (4) 23 15 YA42 23 (4) e that all of the records that are required to be inspected are available and kept up-to-date. (The previous timescale of 31/03/06 not fully met). The Registered Providers must ensure that the frequency of maintenance and testing of equipment is sufficient to meet the health and safety standards for the home. All of the staff working in the home must take part in regular fire drills to evidence that they are aware of the procedures. 30/09/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA1 YA10 YA19 YA32 Good Practice Recommendations That, the Service Users Guide, and other information, is produced in the formats which most meet the needs of individual service users. That limited records are kept in the dining room to ensure that confidentiality is maintained. That the information on health and medical needs are only maintained in one area so that there is a continuous record to show health needs, appointments and their outcomes. That the training schedule previously in use is maintained so that easily accessible information can be provided to demonstrate that staff training is up-to-date and when it is required to be updated. As part of the quality monitoring procedures, a system should be introduced which clarifies the type and frequency of servicing required for all of the equipment used, and training to be undertaken by staff, to show compliance with the Care Home Regulations 2001. 5 YA42 Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Halliday Square, 57 DS0000027708.V300125.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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