Inspection on 30/12/05 for Halliday Square, 57

This inspection was carried out on 30th December 2005.

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 29 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 24/07/06

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 Unannounced Inspection 14.50 30 December 2005 th Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 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.V270638.R01.S.doc Version 5.0 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.V270638.R01.S.doc Version 5.0 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) National Autistic Society Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 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, and is purpose built. The centres of West Ealing, Ealing Broadway and Southall can be reached by public transport from the nearby Uxbridge Road. There are two local shops on the estate, which is close to Ealing Hospital. The communal facilities consist of a lounge, large dining room and a kitchen on the ground floor, and a lounge/activity room on the second floor. Changes were being made during this inspection to convert the ground floor office to a bedroom, to accommodate a service user with poor mobility. The third communal room, on second floor, which was previously used as a lounge and a staff sleeping-in room, has become the staff office. The service user’s former bedroom has become the staff sleeping-in room. 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. There is a small garden to the rear of the property and private parking to the front. The home has a Manager Designate, who also manages a care home for two service users, located about one mile away. There is a Service Coordinator for each of the houses and a joint staff team. 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 sleeps in. The staff provide support with personal care, practical tasks and activities. The home has its own sevenseater transport. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced on the 30th December 2005 from 2.50pm. Three of the Halliday Square service users were present on this visit, the remainder being on holiday with their families for Christmas. The two service users from Golden Manor, the home that is managed and staffed by the Halliday Square team, were also present and it was found that one of the service users had been staying in the home, sleeping in a lounge. The Manager Designate and senior National Autistic Society manager were informed that this is not permitted and is a breach of its registration as it already has six permanent service users. As the new Manager Designate was not present on the 30th December, a further visit was made on the 12th January 2006 at 10.10am to meet with him and discuss the Immediate Requirements made on the first visit and to carry out the remainder of the inspection. At this visit, builders were present to convert the ground floor office to a bedroom and not all of the files required to be seen, which were being stored in the second floor lounge, could be accessed. The final visit was made on 19th January at 10.45am, when the building work and changes had been completed. The inspection took a total of nine hours. Four of the service users were met during this inspection and nine of the staff. Although there is a small core staff team, who have worked in the home for some years and have provided some consistency, a number of newer staff are in post and there are four full-time vacancies. Unsuccessful recruitments have led to the home being without a Registered Manager since October 2004 and this has impacted on the efficient running of the service. For an assessment of all of the key standards, this report should be read in conjunction with the unannounced inspection report of 9th August 2005. There were five requirements at the inspection of August 2005 and three of these have been met. Two are restated but a further twenty four have been made. What the service does well: What has improved since the last inspection? Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 6 A Manager Designate has now been appointed for the home after more than a year without a Registered Manager and following several unsuccessful recruitments. The plan to provide a service user with poor mobility to have a ground floor bedroom has come to fruition. What they could do better: Two Immediate Requirements were made on the first visit of this inspection, two regarding medication administration and one for the COSHH materials stored in an unlocked cupboard. Untrained staff were administering medication which had been dispensed from the original containers into “dosette” boxes. A broken lock on a cupboard containing hazardous materials had not been reported or the contents of the cupboard removed. Action was being taken to comply with the Immediate Requirements. Other medication procedures, such as the disposal of discontinued medication, are in need of improvement. The Inspector was informed that the National Autistic Society are to improve their medication administration procedures. Service users and the representatives have not been provided with the full information about fees and the care home’s charges. These should be available at the point of admission, and the National Autistic Society needs to ensure that these are now provided within a reasonable timescale. Staff did not all show an awareness of the risk assessments and guidance in place to support service users. It must be demonstrated, by training and through supervision, that staff are fully aware of the procedures for keeping service users safe. Areas of concern include the storage of COSHH materials, health needs and medication. The record-keeping in the home was found to be in need of improvement, particularly in the areas of health records, maintenance and repairs, training and recruitment. Policies and procedures were not all seen to be current. The record of complaints was not available for inspection. The fire risk assessment was still required to be fully completed, to include information regarding the service user who smokes. Although training records have been made available at the last inspection, these had not been maintained. Whilst specialised training is provided by the National Autistic Society, an examination of the files showed that some of the basic training courses had not been undertaken or updated. These included first aid and medication. It also needed to be evidenced that staff were fully aware of the Protection of Vulnerable Adults procedures. Although National Vocational Qualification training has commenced for some staff, the National Minimum Standard of having 50 of the care staff training to Level 2 or above has not been met. An Action Plan is required to show how this will be achieved. Supervision needs to be shown to take place regularly to meet the National Minimum Standards. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 7 The procedures for managing service users’ finances were not found to be sufficiently robust and a number of changes need to be made. This included the storage of the money and the verification of the insurance cover for the home. The position regarding the insurance cover, in respect of the service user who carries out small repairs in the home, was also required to be confirmed. The premises must only be used for the accommodation of service users in accordance with the information included in the Statement of Purpose and its registration. Whilst the home is generally maintained in a good condition, some maintenance work was required to the second floor bathroom, with repairs to the tiles and removal of mould. There are vacancies for four full-time support workers. While it was intended to advertise these internally, the Registered Providers need to ensure that every effort is made, with robust recruitment procedures, to employ a full staff team to provide the consistency and continuity required by the service user group. The staff roster available on the first visit was not available in a format that showed the staff had worked the shifts. The Manager Designate took action to improve how rosters would be recorded so as to provide an actual record of the staff who had worked each shift. The recruitment processes were required to be improved at the August 2005 inspection. These improvements are still required. At this inspection it was found that a staff member had been employed without a POVA First check or Criminal Records Bureau disclosure being in place. The Registered Providers must ensure that staff being employed have all of the required checks before commencing. Staff who carry out recruitment must have the training to be able to do so in accordance with the Care Home Regulations 2001 and current employment legislation. Although an accreditation review had been undertaken for the National Autistic Society in 2005, it did not provide for a full review of the quality of care, showing how any improvements could be made. 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.V270638.R01.S.doc Version 5.0 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.V270638.R01.S.doc Version 5.0 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, 4, 5 Information is available to assist prospective service users and their representatives to gain knowledge about the services and facilities available in the home, in specialised formats to suit individual needs. Service users and their representatives do not have the full details about all of the fees and these need to be made available in the contract/terms and conditions. No new service users have been admitted, so the key standard could not be fully assessed. EVIDENCE: The Statement of Purpose and Service Users Guide will require updating to accommodate the details of the new manager and other staff changes that have taken place. It was recommended at the last inspection that the Statement of Purpose be streamlined, in accordance with Schedule 1 of the Care Home Regulations 2001, to make it easier to access and to summarise for the Service Users Guide. This had not been carried out, but the Manager Designate now has plans to do so. The changes to the accommodation and details of the new staff will also need to be included in the revised version. No new service users have been admitted since the last inspection in August 2005 so the admission procedures could not be fully assessed. However, information on the admission criteria is contained in the Statement of Purpose and a six-month trial placement is offered. The National Autistic Society undertakes a specialised assessment to try to ensure that the prospective service users are suitable for the home and their needs can be met. To support Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 10 the needs of the service users, there are specialised National Autistic Society training courses in understanding autism which staff attend. Work has been carried out to enable one of the current service users to remain in the home. Alterations to the home had been proposed some time ago to accommodate the service user whose mobility needs have changed and who required ground floor accommodation. This work commenced and was completed during the course of this inspection. The service user is able to continue to use the stairs to access the bathrooms, and a ground floor shower room and toilet are also available. Information about the some of the terms and conditions are contained in the Service Users Guide and in a specialised format. However, the service users have not yet been issued with contracts/terms and conditions by the National Autistic Society which should contain details of their fees, rent and other financial obligations. The Inspector was informed that the National Autistic Society is undertaking this work currently. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 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): 7, 8, 9 Service users were observed to be supported to remain as independent as possible and assisted with their decision-making where appropriate. It was not demonstrated that new staff were fully aware of all of the health guidance and risk assessments for the service users. EVIDENCE: The service users’ care planning files were in the process of being streamlined following the office move and could not be fully examined on this inspection. The samples seen contained care plans, details of the annual reviews, as well as health information. Service users were seen, during the course of this inspection, to make decisions about the activities they wished to undertake, including going out independently to the local shops and to Ealing Broadway. Another service user was supported to get a selection of DVDs for the service users to watch. Boards with symbols are used to assist some of the service users to be aware of, and plan, their activities for the day. Appropriate communication systems, such as Makaton, are used where required. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 12 A variety of risk assessments were seen to be in place, including those for service users being accompanied outside of the home. Although there is a system in place for staff to sign to say they have read the risk assessments, the documentation had not been signed by the newer members of staff, three of whom were working, without more experienced staff, on the afternoon of the first visit. None had signed the guidance for supporting a service user to self-administer insulin and were not fully aware of them. One of the Service Coordinators said that new staff had read the information, as part of their induction, but it had been an oversight that it was not signed. The personal files for the service users and staff will now be stored in the second floor office. General information is stored in a locked cupboard in the dining room. Staff were observed to use this area for writing notes regarding individual service users, some of which is left out of the cupboard, and it needs to be ensured that the service users records are stored away when not in use and maintained in a confidential manner. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 Service users are given the opportunity to develop their interests and to maintain their skills, with specialist day services being provided. Strong family links are maintained. EVIDENCE: Information is displayed in the dining room, which gives details of the main meal for the day, and of the tasks that each service user is designated to undertake to help with the meals. This might include help with cooking, laying the table or helping to clear away. On one day a week the service users have the opportunity to carry out individual tasks and pursuits, usually with the support of their key worker. This may include domestic chores, shopping and going out to lunch. The National Autistic Society runs a day service in Acton which is attended by most of the service users. One service user chooses not to attend any organised day activities. Whilst this is respected, the Manager Designate said that they would like to provide some alternative activities to interest the service user and will continue to try and do so. The home is situated within a modern housing development, close to Ealing Hospital and the Uxbridge Road. There are bus routes to Ealing and Southall Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 14 central within walking distance but only a few local shops. However, these are accessed by the service users, independently or accompanied by staff. Service users attend various leisure activities, including the cinema, and enjoy meals out. One service user was engaged, with great enthusiasm, in sanding and varnishing a stool during one of the visits and is particularly keen on this type of activity. Three of the service users were abroad, during the Christmas period, with their families. Most retain strong links with their families. The National Autistic Society provides the finance for each service user to have a holiday of approximately one week a year, which may be a group holiday. Additional holidays are taken with families. Day trips are also provided and the service users had recently been to the zoo. Information is displayed in the dining room of the meal for the day. Each of the meals taken are recorded on an individual basis. Although most meals were recorded, it is recommended that, where there are gaps, the reasons for these are explained as these may not be obvious without reading the daily notes. Service users help to choose the meals on a weekly basis. No meals were observed during the visits of this inspection. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The recording of the service users’ health appointments was an area which needed improvement and this remains a requirement. New staff were found not be trained to give medication and the administration procedures used did not comply with good practice. EVIDENCE: The Manager Designate said that all of the service users have some support with their personal care. The six service users have the use of three bathrooms and all have wash hand basins in their rooms. A sample of the health records showed that not all of the outcomes of the medical appointments had been recorded. An examination of two of the service user’s files showed the need for improvements in the recording of appointments. It could not be seen that all of the hospital appointments had taken place and details of the visits were not always recorded. The system for recording General Practitioner visits had not been kept up-to-date. The “OK Health Checks”, which are an annual assessment of health needs, had not been fully completed. It was a requirement at the previous inspection that the health recording must be improved and it was discussed with the Manager Designate at this inspection that this remains an urgent area to address with staff. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 16 One service user is involved in self-administering insulin. It needs to be demonstrated that all of the staff are fully aware of the guidance on supporting the service user, as this was not demonstrated at the first inspection. The medication was checked on the first visit and several matters of concern were found. Medication for the service users had been dispensed into dosette boxes for the following four days. Medication should only be administered from the original, labelled container. None of the staff on duty had any medication training. The Service Coordinator was trying to arrange the training at the time of the second visit. An Immediate Requirement was issued to ensure that the double dispensing of medication into dosette boxes was not continued and for staff to trained before being allowed to dispense medication. A quality of temazepam was found in the medication cupboard but a separate register was not being kept. Although staff said that it was no longer being used, it was found not to have been returned to the pharmacy at the last visit to the home and it must be ensured that discontinued medication is returned promptly. The poor practices in medication administration were discussed with the Manager Designate’s line manager, who said that the medication procedures for the organisation were now being improved. A new and larger medication cupboard had been provided for the new office which should assist staff to keep the medication in better order. The Registered Providers and Manager Designate will need to ensure that the medication administration is improved and that all staff who dispense medication are deemed to be competent. Training has now been arranged for the staff on the 1st February and the Manager Designate said that their competency would be assessed after the training has taken place. The standard on ageing, illness and death was not assessed. The service users are all in a younger age group and most have families who would be involved in the event of the deteriorating health of any service user. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Although there is a procedure for making complaints, there was no log kept of those made so details were not available for inspection. There have been no adult protection issues since the last inspection. The procedures for maintaining the service users’ finances in good order need to be improved. EVIDENCE: There is a complaints procedure in place. The complaints file did not contain any concerns or complaints, although there was evidence in one service user’s file that a relative had raised concerns on more than one occasion. One of the staff said that the complaints documentation may have been archived and was advised that details of the complaints must be maintained, together with their outcomes. Reponses were seen to have been provided, in respect of concerns raised, by then Acting Manager. However, it could not be ascertained if any further complaints had been made and the Manager Designate was advised that these must be kept for inspection. There have been no adult protection issues in the home since last inspection. The training records were not available in full to see which of the staff had attended Protection of Vulnerable Adults training. It needs to be demonstrated that staff have the information and training regarding safeguarding adults. All of the service users have their personal allowances paid from the National Autistic Society, by cheque, to the home. Their Disability Living Allowances are paid directly into their building society or bank accounts, which are held in the home. The Manager Designate confirmed that no bank cards or PIN are used. Staff said that receipts are kept for the larger items purchased by the service users but service users may hold small sums for personal use for which receipts are not required. In the sample of records examined, the items for Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 18 which the receipts should be retained, such as clothing, a meal out and a CD, were not recorded in sufficient detail to reconcile the attached receipt with the recorded entry. It was discussed with the Manager Designate, and one of the Senior Coordinators, that a better system is required to show all of the items of expenditure which are made when staff are accompanying the service users. The accounts are kept on a monthly basis and it was recommended that a calculation is made, at the end of each month, of the individual service user’s expenditure on various items. This can be used to assist with budgeting and as a monitoring tool. It was also advised that receipts should be numbered and this information recorded against the expenditure so that it is easy to verify. The service users’ monies are held individually and the cash is checked against the records at each handover. Whilst maintaining the service users’ rights to have access to their money is important, the system of holding money in two areas of the home, with large sums of money being transferred between them, needs to be reconsidered. The Manager Designate was asked to check on the National Autistic Society’s policy for holding money in the home, where it may be held, and the limits for insurance purposes. He was asked to ensure that regular monitoring takes place of the sums transferred from the bank or building society, and of any internal transfers in the home. The system of recording on loose-leaf sheets which can, and were seen to be, easily detached from the files needs to be reconsidered. It is recommended that other systems, such as bound account books, are considered for future use. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 19 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, 27, 28, 29. 30 The home’s environment is pleasant, bright and generally well maintained. Changes to provide ground floor accommodation for a service user with mobility problems were almost complete and have provided a comfortable private space for the service user. EVIDENCE: The ground floor accommodation, which comprises of a lounge, dining room and kitchen, was clean and bright on the first visit and festively decorated. The long planned work on changing the ground floor office to a bedroom was commenced and almost completed during the inspection. The two communal rooms on the second floor, one of which has now become the office, had been used for a variety of purposes, one being an activity room. On the first visit to the home, this room was found to be very cluttered. A sofa bed was being used to accommodate a service user from Golden Manor for the Christmas and New Year holidays, which made the home in breach of its registration. On the second day of the visit, the activity room was being used for the storage of the files, documentation and office furniture. Work was still being carried out at the final visit to the home to get the activity room in order, but it should provide for the service users to have space for a variety of activities and relaxation. One of the service users enjoys crafts and “do-it-yourself” activities and will have space to carry out these pursuits. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 20 There is a small, but pleasant, garden to the rear of the properly. The last visit of the London Fire and Emergency Planning Authority in August 2005 found the fire precautions were satisfactory. However, the Fire Risk Assessment does not include all the areas of risk that need to be considered and there is limited information on the fire precautions in place to minimise risk. Information on the service user who smokes had not been added to the fire risk assessment although are included in his personal file. This information was given to the Manager Designate and a requirement has been repeated for the information to be included. The service user who has had the bedroom provided on the ground floor was very pleased with the new facility. Good storage for videos, CDs and other personal items have been provided. Another bedroom was seen, with the service user, which was nicely furnished and personalised. Staff said that the service user would continue to be able to use the first floor bathroom, and a shower room and toilet are available on the ground floor. There are three bathrooms, including two showers, for the use of the six service users and the staff. All of the rooms have washbasins. Some improvements need to be made to the fabric of the first floor bathroom, which had small areas of mould and gaps in the tiles. None of the service users require specialised equipment at the present time. With the exception of the activity room, which had been untidy at the first visit to the home, and was in the process of being reorganised at the last visit, the shared spaces were bright and pleasantly furnished. Staff use the dining area for writing notes and other administrative work and it needs to be ensured that this does not encroach on the service users’ use of the area. Service users were able to make use of part of the second communal area on the second floor in the past and the changes have resulted in a loss of this facility. One of the service users from Golden Manor also makes use of the home’s computer at times and it needs to be ensured that the communal spaces are still sufficient to meet the needs of the Halliday Square service users. A part-time cleaner is employed. With the exception of the activity room, the home was found to be clean and tidy on the visits to the home. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 21 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, 33, 34, 35, 36 Although some of the vacancies are covered by regular relief staff, the four vacancies need to be filled to ensure that there is consistency and continuity for the service users, which is particularly important for this service user group. The Registered Providers need to make every effort, with appropriate recruitment procedures, to fill the posts. EVIDENCE: The staff employed work at both 57 Halliday Square and Golden Manor. The manager is responsible for the overall management of both homes and there are two Service Coordinators, for each of the homes, and two seniors. The staff team carry out sleeping in duties at both homes and there are designated waking night staff for Halliday Square. The home has been without a Registered Manager since 2004, and without one of the Service Coordinators, as one post holder had been the Acting Manager in the interim period. There are two members of staff on duty at Halliday Square on the early shift and three on the late shift, while the other home has single staff cover. At the time of this inspection, there were four full-time vacancies. The Manager Designate said that internal advertising is due to take place, but the Registered Providers must ensure that every attempt is made to fill the vacancies by appropriate advertising. Members of the relief team are covering the vacancies at the present time and one agency staff was being used. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 22 The National Autistic Society provide staff with specialist training to work with people with autism. The three new staff who had commenced in the home, in October 2005, two of whom are relief staff, said that they had completed the National Autistic Society induction. However, an up-to-date training record was not available for inspection and the files did not contain details of all of the basic training undertaken. The files indicated that a long-term member of staff had not attended some of the basic courses, including first aid. The Senior Coordinator for Halliday Square said that there had been some gaps in the training programme earlier last year but that this was now improving. The Manager Designate must ensure that all of the staff have the basic training required. An induction pack has been produced but had not been completed for the new staff. Training and induction records must be available for inspection and be current. One Senior Coordinator has the NVQ Level 4 and the second Senior Coordinator is undertaking the same qualification. Two support staff are commencing NVQ Level 3. The home does not meet the National Minimum Standards of having 50 of the care staff trained to National Vocational Qualification Level 2 or above and is required to have an action plan to show how this will be met. The Senior Coordinator, who is an NVQ assessor, will be undertaking assessment of the eligible staff. She said that those staff, who have more than six months’ service, have been registered to commence. New staff are competing the Learning Disability Framework Award and should be undertaking their National Vocational Qualifications when their six month probationary period is completed. At the first visit of this inspection, the staff roster available did not show the staff who were on the shift. Although some of the information on changes was contained in the home’s diary, previous rosters did not show who had, in fact, worked. This was discussed with the new Manager Designate on the second visit and changes had commenced by the third visit to maintain a master roster, with details of the staff who had actually worked on the shift. A sample of three staff records, for newer members of staff, was examined. It had been a requirement at the previous inspection that, to support the safeguarding of the service users, the employment histories needed to be complete and references needed to contain the dates of employment so that any gaps in the work record could be identified. In the sample seen, there were references without dates of employment and not from the last employer. One member of staff had been employed without the Criminal Records Bureau disclosure being received or a POVA First check being obtained. Staff records were not being maintained in good order. The information for the agency member of staff currently working was not available for inspection. The Manager Designate was advised that the record keeping must be improved Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 23 and the information in place must be up-to-date and in accordance with Schedule 2 and 4 of the Care Home Regulations 2001. Staff must not be employed prior to the Criminal Records Bureau disclosure or POVA First check being obtained. The Registered Providers must ensure that staff who are carrying out recruitment have sufficient training and guidance to understand their responsibilities with regard to the Care Home Regulations 2001 and employment legislation. It was not demonstrated that regular supervision of the staff has taken place, and the Manager Designate had put into place a new schedule for the future sessions to be undertaken by himself, the Senior Coordinators and the seniors. It was confirmed that the staff carrying out supervision have had training to do so. To meet the National Minimum Standards, the staff will need to have a minimum of six sessions a year. It is recommended that, because of the number of staff involved in undertaking supervision, a schedule is maintained by the Manager Designate which demonstrates when these sessions have taken place. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 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, 40, 41, 42 While the lack of a permanent manager has impacted on the recording and management systems, the staff have tried to maintain a good standard of care and support to the service users. The Registered Providers must ensure that homes without permanent management cover have the support to maintain management systems, training and record-keeping. EVIDENCE: There has been no Registered Manager in post since 2004. One of the Senior Coordinators was the Acting Manager until December 2005, as several unsuccessful recruitment drives had taken place. The Manager Designate commenced employment on 6th December 2005. He is in process of applying to the Commission for Social Care Inspection for registration. The Manager Designate has NVQ Level 3, NVQ Level 4 in care and the Registered Managers Award. He has previously been the Registered Manager of a care home. The lack of a Registered Manager, staff changes and vacancies have not assisted in providing consistent management in the home. Because the service user group benefit from continuity and consistency, the recruitment and Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 25 retaining of a permanent staff team is of particular importance. The Registered Providers must ensure that homes without permanent management cover are supported with sufficient resources to provide good quality care to the service users, leadership and support for the staff, and maintenance of the systems. The Registered Providers’ representatives make regular monthly visits to the home under Regulation 26 of the Care Home Regulations 2001. However, these are not detailed, generally providing only a score of each of the areas which are examined. Therefore, it could not be ascertained fully if the information on the complaints, testing of equipment and finances had been checked. A National Autistic Society senior manager informed the Inspector that some changes to the reports are planned at a national level. An annual Accreditation Report is undertaken by an external consultant for the National Autistic Society. The last was carried out in June 2005 and a copy of the report was provided at this inspection. The report covers health needs, including diet, and communication. Observations on the environment, activities content, organisation and resources, and teaching and learning methods all received a satisfactory scoring. The responses from the questionnaires from representatives were scored as satisfactory, good and excellent. The report did not contain information on service users’ views although a pictorial National Autistic Society questionnaire is available. Recommendations were made on providing a problem-solving approach to enhance the development of independence and on compiling communication profiles for the service users. While this goes some way towards the review of the quality of care, this does not fully meet Regulation 24 of the Care Home Regulations 2001 as not all areas of support are covered in any detail and the service users’ views did not form part of the report. The National Autistic Society has a large number of policies and procedures and these appear to meet those required by the Care Home Regulations 2001. However, there was no index available to show how up-to-date these were and when they had been reviewed. A small sample showed that the review dates had passed and the Manager Designate agreed to obtain a list of the current policies and procedures to ensure that they are up-to-date. Although there is a procedure for staff signing the policies they have read, this did not appear to have been continued for the new staff. The Manager Designate, at the second visit, was in process of trying to find all of the documentation relating to the regular servicing and maintenance contracts. In recent months, not all of the monitoring systems in place appear to have completed, including the health and safety checks. It had been noted, on three occasions recently, that one of the lounge doors did not close properly when the fire alarm was activated, but it was not clear when this had been reported and repaired. The records do not clarify which of the fire points has been tested and there were occasional gaps in the records. Two files containing Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 26 details of the fire precautions and tests were in operation, which makes monitoring difficult. No action was seen to be taken when water temperatures were being recorded above the recommended safe levels. Among the documentation that was located, it was found that the Landlord’s Gas check was carried out in April 2005, and the fire extinguishers were checked in January 2005. Small electrical appliance testing was seen, by examination of the electrical equipment, to have taken place in November 2005. However, the documentation for this was not available. The last testing of the electrical circuits appeared to be in 1999. An Immediate Requirement to remove inappropriately stored COSHH materials, which were in a cupboard with a broken lock, was made on the first day of this inspection. A member of staff removed the hazardous materials to a safe place and one of the service users reaffixed the padlock to the door. Staff must be vigilant in ensuring that broken equipment is reported and repaired. The service user very much enjoys handicrafts and “do it yourself” tasks. Staff said that he had recently fixed a curtain pole in the dining area. The Manager Designate was asked to ensure that the risk assessments are in place for the service users to carry out the tasks and to ensure that the home’s insurance will provide cover. Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 2 Standard No 22 23 Score 1 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 2 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Halliday Square, 57 Score 3 2 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 3 2 2 X DS0000027708.V270638.R01.S.doc Version 5.0 Page 28 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5(1)(b)(c) 17(2)(8) 13 (4) (a) b) & (c) 12 (1) (a) & (b) Requirement The National Autistic Society must provide the contract/terms and conditions to the service users. It must be ensured that all staff are fully aware of the risk assessments and guidance for the service users. Further monitoring of service users files is required to ensure that all of the outcomes of health issues are fully documented to show that action has been taken appropriately. (Previous timescale of 31/10/05 not met). All staff must receive training and be deemed to be competent before dispensing medication. IMMEDIATE REQUIREMENT ISSUED. All medication must be dispensed in line with Royal Pharmaceutical Guidelines. IMMEDIATE REQUIREMENT ISSUED. The staff responsible for the disposal of medication must ensure that there is prompt disposal of discontinued items. DS0000027708.V270638.R01.S.doc Timescale for action 31/03/06 2 YA9 28/02/06 3 YA19 28/02/06 4 YA20 13 (2) 03/01/06 5 YA20 13 (2) 03/01/06 6 YA20 13 (2) 28/02/06 Halliday Square, 57 Version 5.0 Page 29 7 YA22 8 YA23 9 YA23 10 YA24 11 YA24 12 YA32YA35 13 14 15 YA32YA35 YA33 YA33 16 YA34 A record of all complaints made by service users and others, together with the action taken, must be maintained for inspection. 13 (6) It must be demonstrated that staff have the information and training to understand the adult protection procedures. 13 (6) The procedures in place to manage the service users’ finances must be improved to include better procedures for the monitoring of records, recording and keeping of receipts, storage of cash, and amount of cash held. 4(1a-c) The premises must only be used 4(3) for the accommodation of 23(1a) service users in accordance with the information included in the Statement of Purpose and its registration. 23 Improvements must be made to the fabric of the first floor bathroom, including the removal of the areas of mould and repair of the gaps in tiles. 18(1)(c)(i) All staff must undertake the basic training courses, including first aid, updated where required. 17 (2) 6 The training and induction (g) records must be available for inspection. 18 (1) (a) Every effort must be made, with robust recruitment procedures, to employ a full staff team. 17 (2) (7) A roster of all staff, and the shifts and times they have actually worked, must be maintained and be available for inspection. 19 (1) Staff must not be employed without the POVA First check or Criminal Records Bureau disclosure being in place. 17 (2) (11) 22 DS0000027708.V270638.R01.S.doc 28/02/06 31/03/06 28/02/06 31/01/06 31/03/06 31/03/06 28/02/06 30/04/06 28/02/06 15/02/06 Halliday Square, 57 Version 5.0 Page 30 17 YA34 18 (1)(c) (i) 19 (4) 18 YA34 13 (6) 19 (4)(b)(c) 19 YA35 18 (1) (c) (i) 20 21 YA36 YA39 18 (2) 24 22 YA41 17 (1)(2) 23 YA42 13 (4) 23 (2) (c) 24 YA42 13 (4) 25 YA24YA42 23 The Registered Providers must ensure that staff being employed have all of the required checks before commencing. Staff who carry out recruitment must have the training to be able to do so in accordance with the Care Home Regulations 2001 and current employment legislation. The recruitment processes must be improved to ensure that full information is obtained regarding staff employment records. (Previous timescale of 31/10/05 not met) An Action Plan is required to show how the home will meet the National Minimum Standards of having 50 of the home’s staff qualified to National Vocational Qualifications Level 2 or above. Regular one-to-one supervision of staff must be undertaken. A review of the quality of care, together with improvements to be made, must be undertaken at regular intervals which includes consultation with the service users. 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. Systems must be in place to ensure that staff report faulty equipment and that it is repaired or replaced, within appropriate timescales, to maintain health and safety in the home. That no COSHH or potentially hazardous materials are left in cupboards which cannot be locked. The fire risk assessment must be fully completed, to include DS0000027708.V270638.R01.S.doc 31/03/06 28/02/06 31/03/06 31/03/06 30/04/06 31/03/06 28/02/06 30/12/05 28/02/06 Page 31 Halliday Square, 57 Version 5.0 26 YA42 13 (4) information regarding the service user who smokes. (Previous timescale of 15/10/05 not met) The Manager Designate must ensure that the risk assessments and insurance cover are in place for the work carried out by any service user undertaking repairs. 28/02/06 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. Refer to Standard YA1 Good Practice Recommendations That the Statement of Purpose is revised to make it more user-friendly, and in line with Schedule 1 of the Care Homes Regulations, so that a summary can be included in the Service Users Guide. That, where meals are not taken, the reasons for this are documented to ensure that a complete record of meals maintained. That a different system of maintaining financial records, in bound books, is considered. In view of the number of staff carrying out supervision, a schedules of sessions held should be maintained. 2 3 4 YA7 YA23 YA36 Halliday Square, 57 DS0000027708.V270638.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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. 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