Inspection on 08/12/05 for Middlefield Manor Residential Home

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Middlefield Manor Residential... 29/04/08

Middlefield Manor Residential... 04/05/07

Middlefield Manor Residential... 11/10/06

Middlefield Manor Residential... 23/05/06

Middlefield Manor Residential... 12/07/05

Middlefield Manor Residential... 17/11/04

Middlefield Manor Residential... 15/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Middle Field Manor Residential Home The Street Barton Mills Bury St Edmunds Suffolk IP28 6AW Lead Inspector Claire Hutton Unannounced Inspection 8th December 2005 10:00 Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Middle Field Manor Residential Home Address The Street Barton Mills Bury St Edmunds Suffolk IP28 6AW 01638 583549 01638 583540 saraanderson@nas.org.uk 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 Mrs Sara Louise Kindler Anderson Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2004 Brief Description of the Service: Middlefield Manor is owned by the National Autistic Society (NAS) and is registered to provide personal care for up to fifteen younger adults with a learning disability, specifically, autistic spectrum disorder. The building is a large Georgian detached house set in four acres of grounds, located at the end of a private driveway in the centre of the village of Barton Mills. The home is divided into two separate units; Norfolk House and Cambridge House, each having their own separate enclosed garden and separate staff team. All the home’s bedrooms are single with one bedroom benefiting from en-suite facilities. There is no passenger lift to the first floor and no resident accommodated has mobility problems. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the fourth visit to the home this year by CSCI inspectors. Two previous visits were conducted on 12th July and 24th November 2005. The key standards are assessed over these visits. Any standards that were not met were reassessed at this visit. The reason for the additional visit on 24th November 2005 was in response to concerns over the numbers of staff on duty. Two requirements and two recommendations were made in relation to staffing at this time. On 12th October 2005 a pharmacy inspector from the CSCI also visited the home to investigate a complaint relating to medication practices and the findings are incorporated in this report. This unannounced inspection took place mid week in December 2005 and lasted eight hours. In the morning an inspector from environmental health accompanied the CSCI inspector as they had concerns to follow up relating to the environment and reporting of incidents through the RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences), which is health and safety legislation. During this inspection several residents were met, but none spoken to in private, five care staff were spoken with and the advocate was met and spoken with in private. Several parents from Norfolk House were also spoken with by telephone before and after inspection. The registered manager is currently not at the home. The acting manager and area manager were present through most of the inspection process. The acting manager received feedback including an immediate requirement relating to staff numbers. Records inspected included a care plan, risk assessments, incident reports, action plans from previous requirements, policies, staff meeting minutes, staffing rosters, menus and records relating to medication. What the service does well: Middlefield Manor has a core staff group who have worked at the home a number of years and therefore the residents and parents know those well and have developed a good relationship. The environment is not ideal, but has been divided into two separate houses with a separate staff team in each house. The environment is kept very clean and generally well maintained. Each resident had a plan of care in place with a plan of activities set out for each day. The opportunities that are offered are appropriate to the needs of adults with autism and a choice available. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 6 The home has developed links with an advocacy service. The individual who is visiting the home and developing relationships with residents was clear about her values and role within the home. What has improved since the last inspection? What they could do better: The home did not have sufficient staff rostered on duty to meet the needs of the residents and an immediate requirement was left with the acting manager. This immediate requirement was actioned and he has provided sufficient evidence to show that the home had sufficient staff rostered over the Christmas period and the month of January 2006. At the last inspection a requirement was made to ensure the requirements made under health and safety were actioned. Matters relating to this were still outstanding and the environmental health officer was seeking compliance. The environmental officer has reported separately on these matters to the home. Staff were seen to be kind to residents but did not practice values such as respect and privacy. The manager agreed that staff should undergo training on dignity, privacy, choice and respect. In addition there are concerns around staff understanding how to manage behaviour that challenges. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 7 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. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 and 4 People who use this service can expect to have information available that will enable them to know what is offered and what to expect from the service. EVIDENCE: The statement of purpose and service users guide was previously examined and met the regulations; no changes to this document have been notified to the CSCI. No new residents have moved into Middlefield Manor since the last two inspections when the process of assessments and introduction to the home was assessed fully and found to be met. Resident trial periods could last up to 6 months and were based around individual circumstances. This home does not accept any emergency admissions due to the nature of the resident group and any introduction to the home would have to be well planned. At a meeting on 24th November 2005 with the area manger and acting manager it was agreed that Middlefield Manor would not admit any further residents to the home without first consulting with the CSCI. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 and 10 Residents at Middlefield Manor can expect to have a plan of care in place, but currently cannot be assured this is as up to date as required or followed by all staff. EVIDENCE: The care plan for one resident was examined along with risk assessments, and incident reports relating to the person’s challenging behaviour. The care plan was written in May 2004. Elements of the care plan were contradicting each other in relation to how many staff were required to support the individual when in the community. In one section it stated two staff and in another it stated one to one supervision. The risk assessments for 2001 and 2002 were still in the file for staff to read. There had been a serious incident with challenging behaviour in July 2005 and the risk assessments had no evidence of review, even though a member of staff had been injured and the matter had required reporting under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences), which is health and safety legislation. There had also been a recent incident of challenging behaviour that had led to property being damaged. The incident that occurred five days previously and had been recorded on an incident form, but the matter was questioned to see Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 11 if it could have been avoided. Such potential incidents of behaviour that challenges were recorded in the care plan, with clear instruction on how to deal with similar matters, but had not been followed by staff who were on duty. The staff were neither new nor relief and were trained and therefore should have been able to diffuse the situation or prevent it from happening. Upon discussing this with the acting manager he agreed to follow up the matter in formal supervision to ensure staff were aware of care plans and check if staff felt appropriately trained and confident. He also confirmed that the individual resident would have their care plan reviewed along with the risk assessments in place following each new incident. The acting manager explained that the plan at Middlefield is for all residents to have a full person centred plan in place. The process of review had started and five had been completed in the last six weeks. A manager from another care home would be assisting the staff within Middlefield to develop plans and risk assessments. Each resident now had an individual diary to ensure confidentiality in recording and access to records. These were viewed in Cambridge house and found to be in order. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 16 Currently there are not supported links in place with some families and residents are not always treated with the respect and offered choice, therefore a fulfilling lifestyle cannot be assured at all times at Middlefield Manor. EVIDENCE: Before and after this inspection four parents have telephoned the CSCI on a number of occasions about various matters relating to communication at Middlefield Manor. It is their view that they are not always kept informed or consulted about matters that affect their relative. Indeed there was one serious incident upon a holiday in the summer where the appropriate parents were not informed. The National Autistic Society has since written to parents and is in the process of developing a ‘partnership with parents’ whereby a twoway contract will be developed. One social worker has also expressed a view that communication with the home is not always as good as it should be. The home has developed links with an advocacy group and one advocate has been coming to Middlefield for some time and developing relationships with residents to encourage self-advocacy. The advocate was interviewed about her role within the home. She had a good understanding of values that Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 13 promote self-advocacy and expressed her difficulty in supporting residents on occasions. This was partly due to care staff not understanding her role and assuming she was a carer and partly the way of working from staff that did not always encourage choice. She gave an example of a resident being given a meal that day. The resident did not eat it and told the advocate they did not choose it or like it and wanted marmalade on toast. The advocate tried to encourage the resident to approach staff about this choice for themselves, but was unable to get the resident to tell staff. The advocate solved the matter for the resident. During the inspection there was one member of staff that was agitated about a tap that could not be turned off. She involved everyone in this matter whilst ensuring it was dealt with. Indeed she managed to have a plumber come promptly and stop the flow. She insisted that the site of the flowing tap was seen. Without knocking and without the resident’s permission a stranger was led to the tap in a resident’s en suite. This was accessed through the resident’s bedroom and the resident was sleeping in the bed. The resident was disturbed. The matter of respect and dignity for the residents was discussed with the acting manager and he agreed to ensure all staff are trained in values such as dignity, privacy, choice and respect. In relation to meal planning the acting manager explained that since the last inspection they have developed a picture library of meals to offer to resident to choose. He stated that each resident would get to choose his or her favourite meal once a week. The responsibility for recording each individual’s food intake to ensure a balanced meal was now the responsibility of the senior carer on duty in each house. On the day of inspection in Norfolk House the main meal being prepared was pork chops, with potatoes, broccoli cauliflower and sweet corn. For dessert there was mince pies and custard. The mince pies had been decided upon as the staff member had bought them as a treat that day. A member of staff explained that the shopping was done once a week as an activity with the residents, but this week it did not happen due to there being no driver. The budget for food was said to be generous as it was £180 for the week and milk was paid separately. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 A commitment has been made to improve all areas relating to medication, but at the time of this assessment not all aspects could be assured as best practice and supported by policy and procedure. EVIDENCE: On 12th October 2005 a pharmacy inspector from the CSCI visited the home to investigate a complaint relating to medication practices and from that visit he concluded that the complaint could not be resolved, due to the home’s recordkeeping practice particularly in relation to medication being insufficient to account for medicines and allow such an investigation to be undertaken. The home has been informed that a full inspection visit will take place within approximately two months to monitor compliance with the medication standard (YA20). Failure to meet the standard at that time may result in the Commission taking legal action. From the recent Protection Of Vulnerable Adults (POVA) investigation concluded in November 2005 the matter of medication change and the authorisation required for staff to administer different medication was required to be actioned in the form of reviewing the medication policy. The National Autistic Society has written to confirm this is being reviewed and addressed; however the CSCI have requested evidence in the form of the reviewed policy. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 15 A copy of a publication from the Royal Pharmaceutical Society of Great Britain entitled ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ was left with the acting manager. Medication was briefly looked at in Cambridge House at this inspection. There had been an issue relating to administration of medication and the recording of this. The acting manager stated he was working on this to ensure staff administered medication in line with that prescribed. There had been a trail period of two staff administering medication, but this did not appear to decrease the amount of mistakes being made. There was no procedure in place for staff to follow when administering medication to residents. The manager agreed to write one to ensure there was no ambiguity in action required by staff or responsibility. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The National Autistic Society have demonstrated that they are now acting to protect residents and are taking any concerns seriously. EVIDENCE: The home does have a complaints procedure in place and this is posted upon a notice board for all to see. There have been a number of complaints and POVA (protection of vulnerable adults) referrals relating to Middlefield Manor since the last inspection. The complaint relating to medication is commented upon in the previous section. A relative made a complaint around the numbers of staff on shift one morning. This was substantiated. The numbers of staff on shift was then monitored which led to the additional inspection in November 2005. Then at this inspection an immediate requirement was made relating to staffing that was then resolved to the satisfaction of the CSCI. A complaint was made in relation to activities of staff on a holiday. This was referred through POVA as the home had failed to do this. The matter was duly investigated by the CSCI and six requirements and four recommendations made of the home. An action plan was received on how the home would address these concerns. At this inspection the progress on matters was examined. There was progress to note and these matters will further be followed up at subsequent inspections to ensure ongoing compliance. In January 2006 the area manager wrote to the CSCI to update on progress made on these requirements. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 17 At the time of writing there have been a further six POVA referrals made by the home. The local agreed procedure has been followed and matters duly investigated. The manager sent evidence to show that all staff employed have had POVA training. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Middlefield Manor layout and facilities could be further enhanced to meet the lifestyle of the resident group. EVIDENCE: Middlefield Manor currently accommodates 12 residents, seven people in Norfolk House and five in Cambridge House. Norfolk house consists of a range of communal areas, a lounge looking out into a lovely spacious garden, a dining area and a separate smaller eating area and a kitchen, which are all accessible by the residents. The house is nicely presented and decorated. Following the two previous visits from CSCI recommendations were made to make changes to the layout of Cambridge house, in particular the kitchen and lounge area and access to a ground floor toilet. A visit from the environmental health department supported the view of changing access to the toilet. Plans had been drawn up, nearly a year ago to make these alterations however the situation has declined. Instead of addressing more suitable access to the toilet access has been denied as a key code lock placed upon the entrance to the laundry room and toilet. There is no other ground floor toilet accessible in Cambridge House. One resident in particular was affected by these changes as they have difficulty in going upstairs frequently, alternatively they would have to ask staff for access to the toilet. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 19 In the last inspection report it stated ‘The lounge in Cambridge House was due to have new carpet and curtains. This was needed as a hole was seen in the carpet near the window and the window blind was hanging off. Small areas of repair were needed in some bedrooms. One resident had a broken draw another had a hole in their wall’. When the acting manager was asked if the repairs had been addressed he was not aware of the matters, but gave assurances they would be addressed promptly. All areas of the home visited were clean and without odour. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 20 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): 33 and 35 The National Autistic Society have demonstrated that they are now putting in place sufficient and generally well trained staff to meet the needs of residents at Middlefield Manor. EVIDENCE: Five care staff were spoken with, some in private. Staff said they felt supported by managers and had confidence in them. They did however say that at the moment there was a feeling of not all working together. Staff were concerned about the changes currently being introduced to the home in relation to ‘person centred planning’. One member of staff said that because some people had had the training and others had not yet, then the two differing ways of working were causing tension on shift. Another member of staff said that there was a feeling of anxiety and speculation of what the changes will bring. The acting manager confirmed he had supervised all senior staff and that they would now go on to supervise care staff. Upon arrival at the home there was one senior care staff on duty with one relief member of staff. There were five residents in Norfolk House and one resident in Cambridge House. Therefore, there were insufficient staff available to meet the needs of the residents over the two houses. At the last additional inspection staffing levels had been worked out with managers at the home to Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 21 ensure numbers of staff met needs of residents. The rosters for December 2005 were examined and the home did not have sufficient staff rostered on duty to meet the needs of the residents. Therefore, an immediate requirement was left with the acting manager. This immediate requirement was actioned and he has provided evidence to show that the home had sufficient staff rostered over the Christmas period and the month of January 2006. The acting manager sent information relating to staff training following the inspection. The evidence shows that all staff have now undergone training in protection of vulnerable adults. The manager must ensure he is aware of how frequently this training should be repeated as one person was trained in 2003. Also, it stated that all staff have undergone training in managing challenging behaviour. Six of these were trained 3 or more years ago. The provider of this training is Studio III and their recommended retraining timetable is annually, but could be extended up to 15 months in exceptional cases. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 22 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, 38, 40 and 42 The home currently has a manger who is proving effective, but lack of risk assessment and policies cannot promote and safeguard the health, safety and welfare of people who use the service at this time. EVIDENCE: The registered manager is currently not at the home and the National Autistic Society have placed Mr Paul Steward at the home full time to act as manager. Mr Paul Steward has the appropriate experience as he comes from another National Autistic Society care home for adults with a learning disability. He is still studying for an appropriate qualification – that being National Vocational Qualification (NVQ) level 4 and the registered managers award. From staff and relatives spoken with they feel that Mr Steward is doing a good job. Evidence of addressing concerns raised with the National Autistic Society shows that Mr Steward is making progress on matters at the home. From the recent POVA investigation concluded in November 2005 matters relating to access of policy and staff awareness of policies was highlighted. At Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 23 this inspection the acting manager stated that the compiling of policies for access from the computer system was still under way, but that key policies that were highlighted had been posted to staff at home and their receipt and understanding was noted. As well as the medication policy review, review was required of the following policies: Holiday arrangements, drinking, smoking and behaviour/conduct of staff, procedures to be followed in the event of an accident and development of a policy on mobile telephones. Policies should each have the date it was written and by whom. An inspection from the local council in relation to food hygiene and health and safety was conducted on 01/07/05. A copy of the report was given to the CSCI at the previous inspection. The report contained several matters relating to risk assessments and the environment that needed attention. The local council inspector accompanied the CSCI inspector for part of the morning and left another report with the home with requirements to be actioned. One key aspect that was clarified at this inspection was the home’s duty to report RIDDOR in an appropriate manner. Only half a form had been received from the home in July 2005. One other key requirement was risk assessments to be developed around residents’ safety when using the kitchen. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 1 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 3 3 X X X 2 X Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 25 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 2 Standard YA6 YA9 Regulation 15 (2)(b) 14 (2) 15 (2) 15, 17 (1)(a) 12 (2) (3) Requirement The care plans for residents must be updated and known and followed by care staff. Risk assessments must be updated regularly, but always reviewed following an incident connected to the risk. The home must support residents to maintain family links and improve communication with all relevant parties. The daily routines and house rules must promote independence, respect and individual choice, therefore staff must have training and understanding of these principles. On matters relating to medication the home must take the following action: 1.Take steps to ensure full and accurate records for the receipt, administration and disposal of medication are completed at all times in a way that would enable a complete audit trail of all medicines and therefore allow all medicines to be fully accounted Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 26 Timescale for action 28/02/06 28/02/06 3 YA15 28/02/06 4 YA16 28/02/06 5 YA20 13(2) 28/02/06 for at all times. It is suggested that in doing so the home undertakes regular stock counts and reconciles quantities of medicines held in order to promptly identify inadequacies arising. 2.Take steps to ensure full and accurate records are maintained for the supply and receipt of medicines to and from relatives and including medicines taken with staff when on leave with service users. 3. A procedure for the administration of medication must be in place then known and followed by staff. 6 YA24 23 (2)(b) All parts of the home must be kept in good a good sate of repair as detailed in this report. (This is a repeat requirement) Access to a downstairs toilet in Cambridge House must be resolved. All action requested by the recent health and safety inspection must be promptly actioned.(This is a repeat requirement) 28/02/06 7 YA42 13 (4) 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 YA17 Good Practice Recommendations Residents should be offered a choice of menu that respects their individual preference. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 27 2. YA20 It is strongly recommended as a matter of good practice that full and accurate records are maintained for any contact made with relatives in relation to the care of residents and any incidents arising from medication. A copy of the newly revised policy on medication should be sent to the CSCI when completed by the National Autistic Society. 3 4 5 YA35 YA37 YA40 Refresher training in behaviour that challenges the service should be annually in line with recommendations from Studio III. The acting manager should notify the CSCI of the intended timescale for him to become appropriately qualified. All policies and procedures should be freely available to all staff in a written format that is up to date with who wrote it. All staff should sign each policy to say they have read and understood each policy. Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Middle Field Manor Residential Home DS0000024447.V274214.R01.S.doc Version 5.1 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!