Inspection on 09/01/06 for Michael House

This inspection was carried out on 9th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Michael House 10/04/07

Michael House 23/08/05

Michael House 23/11/04

Michael House 05/07/04

Michael House 24/03/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Michael House MacCallum Road Enham Alamein Andover Hampshire SP11 6JA Lead Inspector Laurie Stride Unannounced Inspection 9th January 2006 10:00 Michael House DS0000012058.V267026.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 Michael House DS0000012058.V267026.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. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Michael House Address MacCallum Road Enham Alamein Andover Hampshire SP11 6JA 01264 345800 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) Enham Mrs Karen Mary Sawyer Care Home 23 Category(ies) of Physical disability (23), Physical disability over registration, with number 65 years of age (2) of places Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Agreement has been given for two named persons over 65 years of age to be accommodated at the home (dates of birth are 12.01.27 and 31.07.35) 23rd August 2005 Date of last inspection Brief Description of the Service: Michael House is part of The Enham Organisation situated in the village of Enham Alamein, Andover in Hampshire. The purpose-built establishment is registered for 23 physically disabled service users. The establishment is one of four residential settings on the large site. The main building of Cedar Park houses the medical consulting area and some leisure activities. Michael House provides physical and emotional support to individuals who have a physical disability, sensory impairment or learning disability. The purpose of this service is to enable people with disabilities to realize their full potential both by listening to their expectations, providing a structured work setting, assessing their needs and by providing advice and guidance from health care sources. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two annual unannounced inspections and lasted three and a half hours. The inspector spoke with a member of staff and the home’s manager and viewed samples of the home’s records. It was not possible to speak with residents on this occasion, however three residents were spoken to during the previous visit. The inspector looked mainly at the key standards not assessed at the last inspection and therefore this report should be read in conjunction with the previous report. There were no requirements made as a result of this visit. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 6 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 Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 7 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): None of these standards were assessed on this occasion. Please refer to the previous report of 23 August 2005. EVIDENCE: Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 8 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): None of these standards were assessed on this occasion. Please refer to the previous report of 23 August 2005. EVIDENCE: Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 9 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): 16 and 17 The home promotes healthy eating and upholds residents’ rights and responsibilities in daily routines. EVIDENCE: Residents are assessed on their abilities to undertake household routines within their own accommodation and can choose whether or not to join in with activities. Opportunities exist for residents to participate in structured programmes at the development resource centre and workshop, situated in close proximity to all the homes on the site, and residents’ taking part in the workshop are expected to show commitment such as working to deadlines. This expectation fosters individual responsibility and helps people develop skills for employment. There is a privacy policy statement made within the Charter of Rights provided to all residents and which covers their rights and responsibilities with regard to privacy. Staff knock on resident’s doors and wait to be invited in. All residents are provided with keys to the home and to their accommodation and there is an intercom system which gives residents choice about whether to see visitors or not. Residents receive their mail unopened and assistance is given where Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 10 required in relation to reading and responding to mail. Residents have unrestricted access to the communal areas of the home and grounds. There is a house budgie and the manager confirmed that residents can keep suitable pets in agreement with the home and this would be individually assessed. There is a non-smoking policy in the communal areas. Records were seen showing what food individual residents like and in what portions, whether vegetarian or other special dietary needs are required. The manager said that nutritional assessments followed professional advice and more fresh food was now provided. Residents are consulted in relation to the four-week ‘set’ menus and these can be changed. Menus showed a variety of meal choices and alternatives are made available. Staff monitor residents’ food intake and an occupational therapist is available on-site to assess if appropriate eating aids are required. There is a pleasant dining area and residents can choose to eat in their rooms. Lunch is between 12:30 and 1:30 when most of the residents take a break from the resource and development centre before returning in the afternoon. The evening meal is served between 5pm and 6pm. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 11 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): None of these standards were assessed on this occasion. Please refer to the previous report of 23 August 2005. EVIDENCE: Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 12 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): 23 Training, policies and procedures are in place to ensure an effective response to any suspicion or allegation of abuse. EVIDENCE: Policies and procedures for the protection of vulnerable adults were available and staff induction and training programmes included abuse awareness. In discussion with a member of staff it was evident that he/she knew and understood the reporting and recording procedure. Two of the organisation’s management team had undertaken training to be trainers regarding Protection of Vulnerable Adults (POVA) in December 2005. Training, policies and procedures are also in place with regard to managing any challenging behaviour and aggression toward other residents or staff members. Through discussion with the manager it was evident that any incidents were handled sensitively and fairly and external professional advice sought where necessary. The majority of current residents manage their own personal allowance and relevant records are kept. Residents invest in the bank of their choice or post office savings account. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 13 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): 30 The home has effective systems and procedures in place to ensure the home is clean and hygienic. EVIDENCE: All relevant information with regard to health and safety, hygiene and control of infection is available within the establishment. Protective clothing and laundry bags are available to reduce cross infection. Staff confirmed they receive training in infection control as part of their core training programme. The laundry is modern and appropriately designed with all required facilities and is suitably sited so that laundry is not taken through areas where food is stored, prepared or eaten. All COSHH materials are locked away and a pumpfed detergent system is in place. There is a contract for the collection of clinical waste. At the time of the inspection a very high standard of cleanliness was observed on the premises. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 14 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): 32, 33 and 34 Residents are supported and protected by suitable numbers of qualified and competent staff and the home’s recruitment policies and practices. EVIDENCE: The manager said that out of thirteen care staff, five were currently undertaking NVQ training while others had completed this or were due to enrol. Senior care workers had either completed or were working towards level 3 awards. New employees receive induction training that meets the Skills for Care standard before starting NVQ level 2 training. It is an organisational policy that all staff are supported to obtain NVQ awards. The home also provides staff with a rolling programme of statutory and other relevant training including, for example, health and safety, epilepsy, care planning, disability awareness, professional boundaries, risk assessment, behaviour labelled as challenging and protection of vulnerable adults. The programme runs every 3 months, allowing for new staff and refresher training. The home’s rota clearly showed those staff members on duty or on training. At least three support workers were on duty for each day shift and the registered manager when on duty was additional to these numbers. There is one awake and one sleeping in member of staff overnight. The rota is arranged to ensure that a balance of male and female care staff are on duty. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 15 Permanent care staff also undertake some bank work at Enham and this gives continuity of care to residents. At the time of the inspection it was not possible to unlock a cabinet to access staff personnel files, therefore staff records will need to be assessed at the next inspection. However, previous inspections at all homes on the site had given no cause for concern. The manager confirmed that all required records were held on file and explained the standard organisational recruitment procedures. These records include proof of Criminal Records Bureau (CRB) and POVA (Protection of Vulnerable Adults) checks, two written references for each employee, completed application forms with employment histories, rehabilitation of offenders and health declarations. All staff receive written terms and conditions of employment and job descriptions. Staff recruitment advertisements make clear that appointments are subject to relevant checks. There is a short-listing criteria and records of interviews and subsequent decisions are kept. The manager said that residents are currently involved informally in the selection process, for example showing applicants around the home, and there are plans to further involve residents in the selection and recruitment of staff. If an applicant is successful at interview the home will obtain two or sometimes three written references. Newly appointed staff begin work by shadowing experienced staff. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 16 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 and 39 Residents benefit from a well run home with a clear and effective management structure and well organised systems in place to obtain residents’ views. EVIDENCE: The registered manager is RNMH qualified and is currently undertaking the NVQ level 4 Registered Manager Award (RMA). Mrs Karen Sawyer has previous care and management experience both with Enham and other organisations and has also done voluntary work. She is the senior care manager at Enham and provides formal supervision to the other registered managers. Through observation and discussion it was evident that the senior care manager has a positive working relationship with other managers and staff. There are clear lines of support and accountability within the organisations line management structure. The home has a quality management policy and there are annual performance and quality audit reports on file. The senior care manager undertakes quality Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 17 audits of the other homes in the group, ensuring for example that procedures and risk assessments are effective and evidencing compliance with standards and regulations. Another manager undertakes the audit of Michael House. Health and safety audits are also completed regularly and the manager said that the home was currently working on a food safety plan. Annual resident satisfaction surveys had previously been undertaken with positive results, however it was reported that residents no longer like completing these. Residents’ views are therefore currently sought through monthly meetings and other informal meetings with key workers. Residents chair and also type up the minutes to meetings. The manager confirmed that residents’ relatives and social workers are able to give their views and there is regular feedback from district nurses and from a doctor’s surgery on-site at Enham. Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 18 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 X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Michael House Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000012058.V267026.R01.S.doc Version 5.0 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Michael House DS0000012058.V267026.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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