Inspection on 24/05/07 for Halliday Square, 57

This inspection was carried out on 24th May 2007.

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

The inspector found 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Halliday Square, 57 27/11/06

Halliday Square, 57 24/07/06

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 May 2007 10:30 Halliday Square, 57 DS0000027708.V337172.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.V337172.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.V337172.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.V337172.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th November 2006 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 and 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 a wash hand basin. There are three bathrooms with toilets, one on each floor, and an additional toilet. The home has a manager, registered with the Commission for Social Care Inspection in 2006. Until early in 2007, a two bed registered home was run in conjunction with Halliday Square. The people have now been moved to supported housing but the staff team continue to provide the support to them. The staff team comprises of the Registered Manager, a Deputy Manager, 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. The staff provide support with personal care, practical tasks and activities. Most people attend the National Autistic Society day services. The home has its own seven-seater transport. The weekly fees are from £1198 to £1212. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 24th May 2007 from 10.30pm to 5pm. The Registered Manager was present. Four of the people who live in the home were at their day services, and one was at college. All returned to the home during the afternoon and were met. Two had private conversations with the Inspector. Four support staff were met but there were no visitors to the home. The home has had one vacancy since the last inspection and was in the process of considering a person recently referred. The Commission for Social Care Inspection surveys were sent to the people living in the home, relatives, and the professionals who have contact with the residents. There were five replies from people using the service, three of whom were supported to complete them by their key workers. Two surveys were received from relatives and two from professionals. While these were generally positive, there were some concerns raised regarding a lack of communication with the team. The further development of quality monitoring systems that involve regular consultation with the residents’ representatives, are recommended to encourage an exchange of views. The Inspector toured the home with the Registered Manager and found it to be maintained in good order. The small repairs needed were in hand. There are two comfortable lounges and a dining room for the use of the residents which were seen to be clean, tidy and welcoming. On returning from their day activities, the residents were seen to choose where to spend their time. This included the lounges, their bedrooms and in the dining area with the staff, where people discussed their activities of the day. The residents come from diverse cultural backgrounds and three spend time with their families abroad. While there are no specific cultural needs in regard to meals, people are encouraged to choose recipes and foods which provide a good variety. The religious needs of one person are met by visits to a local church. Continuity has been provided by the retention of the staff and there had been no changes to the permanent staff team since the last inspection in November 2006. The vacancies have been filled but the staff had not yet commenced as references and Criminal Records Bureau disclosures were awaited. The Registered Manager supplied the Commission for Social Care Inspection with a completed Pre-Inspection Questionnaire, which gave information on the people living in the home, staff, maintenance, policies and procedures and records. Samples of the records were examined. All of the information requested during the inspection, including a matrix showing the staff training, and the Service Users Guide, was supplied. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 6 At the inspection in November 2006, there were ten requirements. The Registered Manager has taken action to meet these and two requirements were made at this inspection, one of which is outstanding from the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the documentation required to support people, or their representatives, to understand the services offered by the home and help them to make an informed decision. There are suitable assessment procedures to ensure that anyone wishing to move to the home will be appropriately placed. EVIDENCE: The Statement of Purpose and Service Users Guide have been amended in line with the requirements made at the last inspection. These provide sufficient information to assist people, or their representatives, to make a decision about moving to the home. A copy of the Service Users Guide, in a pictorial format, was included in each person’s file. One person was being considered for the home’s vacancy at the time of this inspection. Documentation regarding the person’s needs had been made available but the management staff were seeking additional information to ascertain if the placement was suitable. The person had made visits to the service. The management staff are aware that, should the primary need of a person referred be outside of the category of the home’s registration, information on how their needs can be met must be included in the Statement of Purpose. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 9 This may be in respect of health needs, the environment, staffing levels and activities or any other service that may be necessary to meet the person’s individual requirements. It was a requirement at the last inspection that each person using the service has information on the terms and conditions from National Autistic Society. A pictorial version has been supplied to each person and copies of there were seen in the files examined. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Progress has been made in improving the care planning files following the last inspection. People are supported in their daily lives to make informed decisions. Risk assessments have been improved to support the people using the service to be independent as possible but to minimise the risk of harm. The encouragement of people to complete some of their own records is good practice. EVIDENCE: The care plans have been updated and provide the information to demonstrate how people using the service can be supported to develop their skills and range of activities. Three of the five files were examined in detail and found to be up-to-date and maintained in better order. There are a number of assessments systems, which go towards informing the care plan, and it is not always apparent how these aid the assessment process. It is still intended that there will be a more person-centred planning system and one staff member is being trained to progress this. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 11 A daily diary is kept for each person, which provides a record of their activities and support. Two of the people living in the home are able to record some of their own notes, such as their record of meals, and this is encouraged. A monthly report by the keyworker and the person concerned is useful to evaluate the residents’ wellbeing and one person is involved in writing their own. Use is made of symbols and photographs to support communication and person uses Makaton signing as a means of communication. Boards with symbols are used for people to plan and to identify their activities for the day. Regular reviews have been carried to which family members are invited. Reports from the day services are also included as part of these reviews. One review was reported to be less than satisfactory, possibly due to poor organisation. The Registered Manager was aware of this and of the need to ensure that the planning process is improved. The people using the service were seen to be able to make decisions about their daily lives, including where they would like to spend their time. Staff were seen to be supporting people to make informed choices. The number of communal areas which are available gives the opportunity for people to choose from variety of leisure activities, such as watching television, listening to music or relaxing, either alone or with company. For those whose communication is more limited, the care plans record their likes, dislikes and preferences, which would assist new staff, or those from agencies, to understand their wishes. In addition to providing improved care plans, the risk assessments have been updated and provide information on the way in which risks are managed. This was a requirement at the last inspection. Information was seen to be appropriately stored. The bulk of personal information is held in the office on the second floor. Records that are used on a daily basis are held in a locked cupboard in the dining room. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people using the service have opportunities for education, leisure activities and holidays to suit their specific needs. Community participation is encouraged through the use of local facilities. Contact with families is maintained and encouraged. People are encouraged to participate in choosing their meals, and a good and varied diet was seen to be provided. EVIDENCE: The feedback from the CSCI surveys included comments that the home provides “ an holistic service” and “the service is excellent at meeting the cultural needs of the service user”. The people using the service are encouraged to attend activities and leisure pursuits, including day services and a college course. The National Autistic Society runs specialist day services for people with autism and these are attended by four of the residents. Two people brought back to the home examples of the craft work they were undertaking at the service. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 13 One person is attending a college course three days a week and indicated that this is enjoyed. The care plans record the type of leisure activities which are undertaken, such as cinema and swimming, and one person said how much ten-pin bowling was enjoyed. Other people get pleasure from shopping and regular trips to the local shop are recorded. Staff said that they had just commenced a programme to improve the independent living skills of one person, who will choose an item for lunch, shop independently for the ingredients, and then prepare the meal. It was noted in the care planning files that evaluations of outings, holidays and activities are undertaken to see how residents benefit from the experiences. The home is located on a housing estate between Ealing and Southall. Buses pass close by, with links to underground and main line stations. The home also has the use of a mini-bus. Use is made of community facilities locally, including the local shops, and one person attends church in nearby Hanwell. Staff spoke of the positive relationships that the residents have built with the people in these community facilities. All of the people living in the home are in contact with their families, and three people regularly spend holidays with their relatives. Two were due to go away in June, when the remaining residents would be going on holiday with staff to Devon. Day trips are regularly provided and one person was able to express enjoyment of having been to Stonehenge and other West Country attractions. The people living in the home are from a variety of different cultures. Although there are no specific cultural requirements in regard to food, it was noted that the menu contained a wide variety of meals from different cultures, many picked from the recipe books which are available. Although no meals were observed on this occasion, the staff said that the they are generally enjoyed and alternatives are available should they be required. Staff said that the residents enjoy trying new dishes. One diabetic resident is catered for. A system is used to involved all of the people using the service in the meal preparation and clearing up and a list displayed in the dining room. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made in the recording of health needs, which provide a better indication of the requirements of each person and how these are met. The recording of personal care preferences would evidence that privacy and dignity have been fully considered. The medication storage is unsatisfactory and solutions are required to minimise any risk to people using the service. EVIDENCE: Personal support is provided in accordance with the care plans for each person, which may vary from full care to prompting. It was noted in the care plans that the same gender care preferences are not recorded. A relative had also raised this. Where there may be a lack of understanding of this, by the people using the service, it is recommended that the views of their representatives are taken into consideration to support both privacy and dignity. Work has been carried out, in accordance with a recommendation made at the last inspection, to separate the medical information held in the care planning files. This has improved access to see how each of the health needs, such as Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 15 visits to the dentist, chiropodist and specialist appointments, is managed. The outcomes of each visit were seen to be recorded. The Registered Manager said that responsibility is given to the senior staff to complete these. It has been raised previously that, because of incidents that were happening in the home, the emotional needs of the some of the residents could have been seen to be supported better, particularly where there had been incidents involving some physical contact. Since the last inspection, the number of reported incidents have reduced as the one of the people involved is no longer living in the home. Staff are recording incidents where the well being of the residents has been affected but there are much fewer and these appear to be managed satisfactorily. Medication is provided in a 28-day monitored dosage system (MDS), which is stored in a cupboard in the second floor office. The day of the inspection was warm and there were concerns about the temperature of the office, which was up to 29°C. Staff were using a fan to cool the area around the cupboard. This was not satisfactory as the cupboard was being left open, when staff were present, to reduce the temperature. A solution must be found to deal with this situation, such as an air conditioning unit, so that medication is stored as required and the people using the service are not put at risk by having access to the medication. When the medication stock that was not in the MDS system was checked, one tablet too many was noted. The previous medication administration record sheet was checked it was found that an error had been made stock number carried forward. As two staff sign to administer medication, it is recommended that two are involved in checking the “carried forward” amounts to minimise any errors. The remaining medication was found to be in order and neatly stored. A representative from the pharmacy supplying the medication carried out an audit in April 2007. The recommendations included the dating of creams and bottles when they are opened, and the medication administration record sheet is used to record all “as and when” medication instead of the separate book used previously. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and adult protection procedures in place are satisfactory. The staff are supported through training to develop their understanding of the procedures to safeguard the adults they support. However, the recording of any concerns raised, and their outcomes, could help to aid communication with the representatives of people living in the home and staff. EVIDENCE: There have been no recorded complaints since the last inspection. Some concerns were noted to have been raised in one of the responses to the surveys sent by the Commission for Social Care Inspection but these had not been made into formal complaints. The Registered Manager was aware of verbal requests being made on behalf of the people living in the home, which had been acted upon. Although there was evidence that one of the issues had been followed up, it is suggested that these are recorded so that it can be shown that action has been taken. Because of their disabilities, it is not always possible for the people using the service to articulate their concerns. As most have families who are in regular contact, ways in which further advocacy could be encouraged is recommended. There have been no adult protection issues in the home. Training had been arranged following the inspection for the remainder of the staff team needing adult protection training and the information regarding the London Borough of Ealing’s safeguarding adults procedures are available. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 17 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. A comfortable and pleasant environment is provided, with good communal facilities which allow the opportunity for both privacy or company. EVIDENCE: No major changes have been made since the last inspection in November 2006. All of the communal spaces were seen on this inspection and were observed to be used by the people living in the home. One lounge provides a television, sensory equipment and the space for indoor activities to take place. The other lounge provides a relaxing area with music facilities. The dining room, which has two large tables and ample seating, adjoins the kitchen and provides for those who like a busier environment. There are French doors to the garden and window seats overlooking it. The garden is quite small but provides a pleasant area, with trees, shrubs and flowers, for people to enjoy and staff said that some like to help with the maintenance. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 18 While the bedrooms are not large enough to have all of the equipment detailed in the National Minimum Standards, such as two comfortable chairs and a table, they appeared to meet the needs of the people using them. Each has a fitted unit with a washbasin and wardrobe and the items, such as television and music facilities, that they are require. There are sufficient communal spaces for people to meet with their visitors in private. The carpet in one bedroom was noted to be in need of replacement as it was torn and could be a potential hazard. The Registered Manager said that the person was reluctant to have the furniture moved for it to be replaced but that it could by done while the resident was on holiday. This needs to be planned to ensure that the work can be carried out. There are sufficient and varied bathing facilities available. The ground and second floors have shower rooms, with toilets. A bathroom and toilet, and an additional toilet, are available on the middle floor where five of the bedrooms are located. One person has poor mobility and has a bedroom on the ground floor and access to a shower nearby. The other people living in the home have good mobility and no other equipment is required at the present time. A domestic assistant is employed for three days a week. The home was seen to clean and hygienic. The Registered Manager confirmed that all the home’s domestic equipment was in good working order and maintenance and repairs had been carried out as required. He confirmed that work to replace a small number of tiles in one of the bathrooms was in hand. Maintenance and servicing are arranged through the landlords, Notting Hill Housing Trust. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 19 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. Staff are supported through regular supervision and meetings. The target of having 50 of the staff team with National Vocational Qualification Level 2, or above, should be reached this year. Staff are supported to undertake specialist training with people with autism. Staff have attended, or are about to undertake, the basic training courses they require. The recruitment procedures are sufficiently robust to support the safeguarding of the people using the service. EVIDENCE: No changes have been made to the staff team since the inspection in November 2006. The Registered Manager reported that recruitment had taken place and the four vacancies, two full time and two part-time, have been filled but references and Criminal Records Bureau disclosures were awaited before they commence. Although there were no new staff records to inspect, a sample of the records held were examined. These were found to be in order, with the information seen to safeguard the people using the service. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 20 In addition to providing care at Halliday Square, the staff team supports two men who were previously in a small registered home in Hanwell. Their home was closed and the men are now living under a supported living arrangement in the same area. Separate rotas are now provided for the two establishments and the files are no longer maintained at Halliday Square. The Registered Manager continues to oversee the supported living service. The home has, in addition the Registered Manager, eleven permanent staff who cover both services. Three have been in post for eight years or more, so know the residents well. There are six senior staff. Although some agency staff are used, the home generally uses bank staff to cover vacancies. Four staff have National Vocational Qualification Level 3 and one, in addition to the Registered Manager, has Level 4. Three staff are undertaking NVQ at Level 2, and three at Level 3. All are due to complete these in the autumn of 2007. Although one of the comments to the surveys said that staff had “appeared to have little training” and “seemed inexperienced”, a wide variety of training has been undertaken by the staff team, some of it being specialist training to work with people with autism. The Registered Manager provided details of the training courses which are needed to ensure that all staff are fully up-to-date and also provided a matrix to show the training staff had undertaken. Dates have been arranged for most of these, although one company had cancelled the fire awareness training. This was rearranged during the inspection. It is suggested that the development of a review of the quality of care would assist in gaining the views of the views of the people visiting the service. The resulting report could address any adverse comments, such as those on training, and demonstrate that any shortfalls in the service are being addressed. A requirement has been made under National Minimum Standard 37, as it has been an outstanding requirement previously. Staff are supported through one to-one supervision sessions which are arranged every 6-8 weeks. Staff meetings are also held on a regular basis. Samples of both records were seen. Although the Registered Manager has been carrying out the supervision sessions, he intends in the future to supervise the senior staff who, in turn, will supervise the support staff. An annual appraisal system is in place. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 21 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the administration and record keeping in the home. The quiet and relaxed atmosphere of the home is beneficial to the people using the service. A review of the quality of care, which is an outstanding requirement, would address issues which have been raised and demonstrate how the staff and the people living in the home have progressed. EVIDENCE: There was a relaxed but positive atmosphere in the home when the people using the service returned home. Improvements have been made in the administration and record keeping which aided the Inspector to carry out this inspection and should support the staff to minimise the time spent on record keeping. A sample of the finances held on behalf of the people living in the home were examined and found to be in order. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 22 The home has benefited from a consistent staff team which has not changed since the last inspection. With five people in the home, and one vacancy, there are two staff on the early shifts and three on the late shift. The four vacancies have been filled but none of the staff had yet commenced. The requirement to have a review of the quality of care has been outstanding. Although the home has an annual accreditation for autism, and has a brief development plan, a full review of the quality of care, which takes into account the views of relatives, staff and professionals, as well as the people using the service, has not been undertaken. Regular monthly visits are made to the home under Regulation 26. From the list provided on the Pre-Inspection Questionnaire, many of the policies and procedures were dated 2003 and may not have been reviewed recently by the National Autistic Society. The Registered Manager was asked to check that these are the latest copies of the policies and provide a more upto-date list if this was not the case. Policies and procedures should be seen to be reviewed regularly to ensure that they are in accordance with the latest legislation and good practice. Where these are kept on a computer system, it is recommended that the National Autistic Society provide a list of the policies and procedures, and their last review dates, to ensure that staff know that they have the latest publication. There were no health and safety issues observed on this inspection although one of the recommendations of the Environmental Health Officer in February 2007, regarding hazard analysis, needs to be completed. The Registered Manager provided information on the maintenance and servicing for the home and a sample of the records was examined. These included the fire records and fire drills have been held each month. Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 2 X 3 3 2 X X 3 X Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 (2) 13 (4) Requirement Timescale for action 30/06/07 2 YA39 24 The Registered Providers must ensure that the medication is stored at a satisfactory temperature, in accordance with the guidance provided. People using the service must not be put at risk by the medication cupboard having to be left open to control the temperature. The Registered Providers must 31/08/07 ensure that a review of the quality of care, with details of any improvements to be made, is undertaken at regular intervals and include consultation with the service users or their representatives. (The previous timescale of 31/03/07 not met) Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 25 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 YA7 Good Practice Recommendations That, where there may be a lack of understanding by a resident regarding the provision of personal care and the privacy and dignity involved, the views of residents’ representatives are taken into consideration and recorded. That two staff are involved in checking the medication stock that is carried forward each month, to minimise the risk of errors. That the recording of concerns by people using the service, relatives, advocates and others, are recorded to ensure that issues can be seen to have been taken into consideration and followed up as necessary. That the Registered Providers provide a list of the current policies and procedures, with their publication and review dates, to ensure staff have access to the most relevant documentation. 2 3 YA20 YA22 4 YA40 Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Halliday Square, 57 DS0000027708.V337172.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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