Inspection on 27/11/06 for Halliday Square, 57

This inspection was carried out on 27th November 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 10 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 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 27th November 2006 10:40 Halliday Square, 57 DS0000027708.V317797.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.V317797.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.V317797.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) Terrymooney@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.V317797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 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 is a small range of 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 a wash hand basin. There are three bathrooms with toilets, one on each floor, and an additional toilet. Changes were made earlier in the year to provide a ground floor bedroom, in the former office, for a service user with poor mobility. The office was relocated to the second floor and the bedroom is now the staff sleeping in room. The home has a manager, registered with the Commission for Social Care Inspection in 2006, who also manages Golden Manor. This is a care home for two service users located about one mile away. Both homes share the same staff team comprising of the Registered Manager, a 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.V317797.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 Monday 27th November 2006 at 10.40am. The Registered Manager was present, together with two staff. Two service users were present, including one from the Golden Manor home, and they were about to go shopping with staff. The inspection was completed at 17.40pm. The inspection process took a total of seven hours. A meeting was being held at Halliday Square, on the day of the inspection, to discuss the imminent closure of Golden Manor in January 2007. A replacement, which may be a supported living home, was in the process of being sought. At the time of this inspection there were five service users living in the home. The sixth service user has been admitted to hospital and was not expected to return to live in Halliday Square. All five service users were seen during this inspection but there was limited contact as the majority preferred to stay in their rooms or be elsewhere in the home. One service user had just returned from a holiday with relatives in America and two service users were due to be away, with their families, for Christmas. The ethnic origins of the service users are diverse and any special cultural needs have been seen to be considered. At the present time, only one service users was attending a place of worship on a regular basis and no other cultural needs were required to be met. Five of the support staff were met. Discussions took place with the Registered Manager about the outstanding requirements and a selection of records, including service users’ care plans, training records and maintenance records were examined. The Registered Manager completed a questionnaire about the service, part of which has been used in the production of the report. For a full assessment of all the key standards, this report should be read in conjunction with the inspection report of the 24th July 2006. At that inspection, fifteen requirements were made. Of those, nine have been completed, and six remain outstanding. An additional four requirements have been made. What the service does well: There have been few staff changes, providing good continuity for the service users. The home is bright and comfortable with sufficient communal space for the service users to have a choice about where they spend their time. Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 6 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.V317797.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.V317797.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, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all of the information is available to support prospective service users or their representatives to make an informed decision about living in the home. The completion of the Service Users Guide and the terms and conditions would aid this process. EVIDENCE: The Statement of Purpose and Service Users Guide were required to be amended at the last inspection to include details of how service users and their families could contact the Commission for Social Care Inspection in the event of wishing to make a complaint. This has been carried out in relation to the Statement of Purpose. The Service Users Guide, is in the process of being updated, in a visual format. As this would support any prospective service users, and their representatives, to make a decision about the home it should be completed as soon as possible. No new service users have been admitted to the home so no assessment could be made of the process. There is a procedure for admitting new service users, which includes a specialist assessment by the National Autistic Society. The terms and conditions have not been provided to the service users with the information, including fees and services, required by the Care Home Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 9 Regulations 2001. This is an outstanding requirement and the National Autistic Society must ensure that that service users or their representatives are fully aware of the facilities and services, including the fees and any additional charges. The Registered Manager reported that among the additional fees, payable by service users, are those for chiropody, toiletries and magazines. Halliday Square, 57 DS0000027708.V317797.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although staff carry out reviews of the service users’ needs, further work is required on the care planning systems to ensure any changes are reflected in the care plans and risk assessments. Where service users, or their representatives, can be involved in the care planning process, it needs to be demonstrated that this has taken place. Service users are generally able to make their own decisions regarding their daily lives and it was demonstrated that staff support them to do so. EVIDENCE: A sample of three care plans were examined. Staff explained that the care planning system is moving towards a “person centred” model but at the present time only one staff member was receiving training to carry this out. Previous systems for streamlining the files have been used, but these appeared not to have been followed by some of the staff. The files examined were not being kept in an orderly fashion, making information on the current Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 11 needs of the service users difficult to find. Although staff carry out a monthly review of the service users’ support and changing needs, it was not possible to see how changes had been incorporated into the care plans and risk assessments. A sample of the files was shown to the Registered Manager and a senior support worker to illustrate this. The development of systems which help to involve the service users, and their representatives, in their own care planning should be encouraged. It was discussed with the Registered Manager that the current system, where there are two files for each service user, needs to be reorganised in the interim period. Some of the older information, though it may be needed occasionally for reference, is not required in the files which are used on a daily basis. The Registered Manager agreed that the files needed streamlining and a system which is easier to use needs to be introduced. It had been required at the last inspection that both the care planning systems and the risk assessments needed updating, and regular monitoring, and these requirements remain outstanding. The service users were seen to be able to choose where to spend their leisure time and staff also supported the service users when they wished to go out, either to the local shops or to a shopping centre. Within the home, the service users were seen to be able to choose whether to spend time alone, or be with staff and other service users. The home has sufficient communal areas for different activities to take place, with the choice of the busy dining room and kitchen area, ground floor lounge, or the quiet room on the second floor. Staff were seen to discuss with service users any decisions which may not have been in the service users’ best interests and to provide them with information to make an informed choice. Halliday Square, 57 DS0000027708.V317797.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. From the records examined and through discussions with staff, all of the service users currently living in the home enjoy a variety of activities, including day activities at the National Autistic Society day service, or at college. Leisure activities, including shopping, are pursued on regular basis. Service users are encouraged to remain independent. EVIDENCE: There was limited interaction with the service users on the day of the inspection as four of the five were at day services, and the fifth service user went shopping with staff. On their return, most preferred to follow their usual routines, which included remaining in their bedrooms. From discussions with staff, and through the records, it could be shown that the service users are able to undertake a variety of activities, including going Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 13 to the cinema, listening to music and shopping. Because of the service users’ autism, staff try to maintain a regular routine wherever possible. Most have families who play an active part in their lives, and have regular holidays and outings with relatives. One service user is now attending college three days a week. The service user is encouraged to undertake outings, when not at a day service, and the records showed a variety of trips to many places of interest, including museums and parks. The remainder of the service users attend the National Autistic Society centre in Acton. Each has a week day spent with staff, which may include shopping and lunch or another activity outside of the home. A daily menu is on display in the dining room, with names of the service users who may assist with the preparation of the meal and the dining room. A varied menu was seen to be provided. The service users and staff come from a variety of cultural backgrounds and the gender mix of the service users is reflected in the staff team. One service user attends church regularly. Information had been recorded to help identify cultural needs but no special needs are required to be met at present. Halliday Square, 57 DS0000027708.V317797.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff need to be more aware of the importance of maintaining all of the medication administration records, particularly when service users go on holiday or homely remedies are given. A system which shows clearly the health needs, the health and medical visits undertaken by service users, and their outcomes, needs to be established. EVIDENCE: An examination of the service users’ files showed that the information needs to be more orderly to ensure that all of their health needs can be easily monitored. It was recommended to the Registered Manager that a separate health file is kept for each service user which can be organised to show that health and medical appointments have been attended and the outcome of each clearly recorded. There was no information on why medication is prescribed and this should be included in the service users’ health files. One service user is insulin dependant, which is self-administered with staff support. A requirement at the last inspection was for staff to record the medication being taken by service users going on holiday and booking it back into the home on their return. This was to ensure that the stock in the home could be Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 15 monitored. Although the medication taken with a service user on a recent holiday had been booked out, no record had been made when the service user returned. Some “homely remedies” were being stored in a ground floor cupboard that was also used for other purposes and was seen to be accessed by one of the service users. Two of the medications, for digestive problems, were out-ofdate. Although a letter was found from the general practitioner regarding homely remedies, those specified for each service user were not detailed. There was no guidance as to when the homely remedies should be administered. The Registered Manager was advised to ask the general practitioner to specify the medication that was suitable for each individual and for each service user to have a separate stock so that an accurate record can be kept. Although some recording had taken place when the homely remedies had been administered, this was found not to be in accordance with the stock held. Staff need to be able to ensure that they can account for all of the medication in the home, from receipt to disposal, and that an audit trail could be undertaken if required. Halliday Square, 57 DS0000027708.V317797.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 adequate. This judgement has been made using available evidence including a visit to this service. A number of incidents haven taken place in the home in recent months which may have affected individual service users, both emotionally and physically. The recording of the support offered, and the opportunity for service users to express their concerns, via the complaints procedures, was not in evidence. The record keeping of the service users’ finances has improved but more detailed recording is still required to ensure that all of the expenditure is easily identified. EVIDENCE: Most of the service users have family members who are able to advocate on their behalf, should a complaint be necessary, or a concern need to be raised, None have been made since the last inspection. There have been some reported incidents in the home where service users have been involved, which may have been upsetting. It is recommended that, where service users have been affected, a record is made of any concerns they may raise. This could be through the key worker, if felt to be appropriate, and the outcomes of any concerns or complaints should be recorded to show how the problems have been addressed. The information on complaints has been amended in the Statement of Purpose, as required at the last inspection, to include details about the Commission for Social Care Inspection. However, some small amendments are still required to change the reference to the National Care Standards Commission. Although there is a more thorough procedure which can be used if a complaint is to be Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 17 made, the timescales for responding could also be included in the Statement of Purpose. The Service Users Guide also needs to contain the information regarding the Commission for Social Care Inspection when completed. Although there have been no issues reported under adult protection, there have been a number of incidents notified to the Commission for Social Care Inspection, regarding one of the service users. These involved both other service users and staff members and eventually resulted in a hospital admission. It was thought at this inspection that the service user would be unlikely to return to the home and a more suitable placement would be found. The majority of the staff have, from the records seen, attended safeguarding adults training. The financial procedures for managing the service users’ monies required changes at the last inspection. The service users now have individual books in which the transactions are recorded. However, some of the transactions have been combined when recorded. It was advised that items should be recorded individually so that receipts can be assigned to each item of expenditure and an audit of receipts more easily undertaken. Some receipts were being numbered and this system should be used throughout the accounts procedure. The money for the service users’ personal allowance is received from National Autistic Society on a fortnightly basis, paid into the service users’ individual accounts, and then money is withdrawn as required. Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is bright and comfortably furnished, with a choice of areas for the service users to enjoy where they may be quiet, enjoy music, or spend time with staff and other service users. More substantial furniture has been purchased to replace the broken items. EVIDENCE: At the last inspection, only two chairs were left in the dining area of the home as most of the chairs had been broken. New chairs, which appeared to be of a more robust design, have now been purchased and were in place. The home is pleasantly furnished, light and airy. There are two lounges, one on the ground floor, and one on the second floor. Although neither was seen to be used on the day of the inspection, both are comfortable and provide the service users with television and music facilities. Some sensory lighting equipment has been provided in the top floor lounge to encourage a relaxed atmosphere. A domestic worker is employed and the communal areas were seen to be clean and tidy. Halliday Square, 57 DS0000027708.V317797.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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been a regular staff team, which provides some consistency. Staff are undertaking National Vocational Qualifications training but the refresher training needs to be provided for all of the staff team working in the home. EVIDENCE: Five of the staff team were met during the course of this inspection. The majority of the staff team have been in post since 2005, and three have been in post for more than ten years. This had provided for continuity for the service users. The proposed changes to the Golden Manor service may have to result in a separation of the information which is currently held jointly. Should the new service be deemed to be a supported living scheme, the Registered Manager will need to ensure that there is a clear definition of the two services, as one will not be registered as a care home with the Commission for Social Care Inspection. The Registered Manager confirmed that the Halliday Square staff will not provide an on-call service to the Golden Manor service users. This will be covered by the National Autistic Society’s out-of-hours service. Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 20 The home had a staff team of twelve permanent staff, including the Registered Manager, Service Coordinator for Golden Manor, three senior support workers and seven support workers. A domestic worker and an administrator are also employed. There were three vacancies for permanent staff. These had been filled previously but two of the staff did not commence work. There is a large team of bank staff who cover for the vacancies. The Registered Manager said that recruitment would take place when the National Autistic Society day centre next advertises. He needs to ensure that the permanent staff team is recruited within a reasonable timescale. Information on the training courses undertaken by staff was provided. This showed that the majority of the staff have attended the basic and specialised National Autistic Society courses. However, some of the bank staff still appear to be in need of updated training and an Action Plan of how this will be addressed is required. Where bank staff have attended suitable courses in other locations, evidence should be provided. The Registered Manager reported that 50 of the current staff team either have a National Vocational Qualification at Level 2 or above, or are working towards this qualification. It was a requirement at the last inspection that regular one-to-one supervision of staff must be undertaken. The Registered Manager showed some evidence that this was now being carried regularly but did not have a system for recording that all of the staff delegated to carry out supervision had met the National Minimum Standards of a minimum of six sessions a year. He said that the notes are passed to him when completed. He was recommended to have in place a system which can demonstrate that all of the staff are regularly supervised. As no new staff had been appointed, the recruitment records were not examined on this occasion. Halliday Square, 57 DS0000027708.V317797.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, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed maintain the records in better order and ensure that staff understand their responsibilities with regard to record-keeping, particularly for medication and finances. Streamlined systems would benefit both service users and staff, providing more time for activities and development. With five senior staff in the home, the monitoring of the records for five service users should not be an onerous task. EVIDENCE: The Registered Manager has been in post for almost a year and has the National Vocational Qualification Level 4 in care and has undertaken the Registered Managers Award. When he commenced at the home in December 2005, a high number of requirements had been made and the home had been without a Registered Manager since 2004. The number has been reduced at the two inspections this year, but attention needs to be paid to the monitoring Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 22 of the record keeping so that there is evidence that the National Minimum Standards and Care Home Regulations 2001 are being fully met. The home had a pleasant and relaxed atmosphere on this inspection with good interaction between the staff and service users. However, there were shortfalls in the record keeping, which all staff have a responsibility to maintain in good order. In particular, staff must be aware of keeping the financial and medication records accurately. By ensuring that the records are well maintained and orderly, there will be evidence that the needs of the service users are being fully met. A requirement was made at the last inspection for a review of the quality of care to be undertaken, in accordance with Regulation 24 of the Care Home Regulations 2001. This needs to incorporate the quality assurance and quality monitoring procedures in the home and an improvement plan should be provided to show how the home will develop. Although an accreditation exercise is undertaken annually, this does not cover all of the areas of quality monitoring. The exercise for 2006 had been carried out in June but no report had yet been received. This requirement has not been fulfilled and is repeated. A list of the location of files is now being kept to assist with inspections, following a requirement at the last inspection to ensure that the records are all available and kept up-to-date. However, as mentioned elsewhere in this report, some records still require improvement. In the information provided by the Registered Manager, it was observed that the policies and procedures of the National Autistic Society do not appear to have been updated since 2004 or earlier. A regular review of policies and procedures should be undertaken to ensure that any current legislation or good practice has been incorporated. It was a requirement that 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. Among the records examined on this occasion were those for Legionella testing, which had not been carried out since 2002. The testing, and that of the small electrical appliances, took place in November 2006. The fire extinguishers, emergency lighting and alarms were tested in January 2006 and a London Fire and Emergency Planning Authority officer visited the home in March 2006. The photocopier has been relocated, as requested by the LFEPA, from under the stairs to the top floor office. The refrigerator and hot water temperatures were being recorded and seen to be satisfactory. The records evidenced that fire drills has been undertaken regularly and the names of staff and the responses of the service users being recorded. This had been a requirement from the previous inspection and has been met. Halliday Square, 57 DS0000027708.V317797.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 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X 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 2 X 3 X 2 X 2 3 X Halliday Square, 57 DS0000027708.V317797.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 YA1 Regulation 4(1)c, 5(1)e,22 Requirement Timescale for action 31/01/07 2 YA5 3 YA6 4 YA9 5 YA19 The Service Users Guide must be completed and included the information on the complaints procedure. (The previous timescale of 31/10/06 not met) 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 & 30/11/06 not met). 12 (1) The care planning systems must (a),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. (The previous timescale of 30/11/06 not met) 13(4) The risk assessments must be 17(1)(3)(a) reviewed to ensure that those in place have been changed to meet service users’ current needs. 12 Further monitoring of service (1)(a)(b) users files is required to ensure that all of the outcomes of health issues are fully DS0000027708.V317797.R01.S.doc 28/02/07 28/02/07 28/02/07 28/02/07 Halliday Square, 57 Version 5.2 Page 25 6 YA20 13 (2) 7 YA23 13 (6) 8 YA35 18 (1)(c) (i) 24 9 YA39 10 YA41 17 (1)(2) documented and to show that action has been taken appropriately. (Previous timescale of 31/10/06 not fully met. The Registered Manager must ensure that staff are following the administration procedures in respect of all of the medication held in stock. Monitoring must take place to ensure that recording is taking place when stock leaves the home and is returned. In order to provide a system which can be monitored and audited, the items and services, purchased on behalf of service users, must be recorded and receipted individually. An Action Plan is required to show when the outstanding training and refresher courses will be undertaken. A review of the quality of care, with details of any improvements to be made, must be undertaken at regular intervals and include consultation with the service users or their representatives. (The previous timescale of 30/04/06 and 30/11/06 not met) The record keeping in the home must be improved to ensure 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 and 30/11/06 not fully met). 31/12/06 31/12/06 31/01/07 31/03/07 31/01/07 Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 26 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 Refer to Standard YA1 YA19 Good Practice Recommendations That, the Service Users Guide, and other information, is produced in the formats which meet the communication needs of the service users. That the information on health and medical needs is separated from other care planning information so that appointments and outcomes can be monitored more easily. That support systems are shown to be in place when incidents occur which affect any service user either emotionally or physically. Any support given to express a concern or raise a complaint should be recorded. That a record, such as spreadsheet, is maintained of the frequency of staff supervision sessions. 3 YA23 4 YA36 Halliday Square, 57 DS0000027708.V317797.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area 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.V317797.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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