Inspection on 01/08/06 for Monro Avenue (54)

This inspection was carried out on 1st August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Monro Avenue (54) 18/02/09

Monro Avenue (54) 12/03/08

Monro Avenue (54) 03/01/06

Monro Avenue (54) 31/03/05

Monro Avenue (54) 01/11/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Monro Avenue (54) 54 Monro Avenue Crownhill Milton Keynes Bucks MK8 0BL Lead Inspector Barbara Mulligan Unannounced Inspection 1st August 2006 10:00 Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 1 Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 2 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 Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 3 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. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Name of service Monro Avenue (54) Address 54 Monro Avenue Crownhill Milton Keynes Bucks MK8 0BL 01908 269116 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) www.macintyrecharity.org MacIntyre Care Miss Nicole Jose Croucher Care Home 6 Category(ies) of Learning disability (7) registration, with number of places Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 5 SERVICE INFORMATION Conditions of registration: 1. That the maximum registered number of service users is temporarily increased by one (1) from the 1st of March 2004 until the 1st of September 2004. It is a condition of registration that the maximum number of service users registered will be increased from six (6) to seven (7) for this sixmonth period. The maximum registered number of service users will return to six (6) once this six-month period has elapsed. 3rd January 2006 Date of last inspection Brief Description of the Service: 54 Monro Avenue is a care home managed by MacIntyre Care and provides personal care and accommodation for six adults with a learning disability. The building is a two storey residential house built in the style of the surrounding properties. The home is situated in a residential area of Milton Keynes and is within walking distance of the local shops, church and local pubs. The home has six single bedrooms on the ground and upper floor and has a secure maintained garden that is accessible to all service users. Access to the upper floor is via stairs or a stair lift. The centre of Milton Keynes is close by offering a large shopping centre, cinema, a range of restaurants and recreational activities, cycle tracks and many other attractions. Fees range from Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 1st August 2006 at 10am. The visit consisted of discussions with the registered manager, care staff and records, policies and procedures were examined. The inspection officer was Barbara Mulligan and the Registered Manager of the home is Nickie Croucher. Twenty-four of the Key National Minimum Standards for Younger Adults were examined. Eighteen of these are fully met and six were almost met. As a result of the inspection the agency has received seven requirements. The inspector received eleven comment cards and these are positive. An example of the comments received includes, “the staff treat my relative with real affection” and “overall I am very impressed and happy with my relatives care”. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the registered manager, staff team and service users for their help and cooperation during the inspection. What the service does well: The home provides a pleasant and comfortable environment in which service users live. Individuals are encouraged to personalise their rooms with their own personal belongings. There are adequate levels of staff on duty who endeavour to meet the personal and healthcare needs of service users. The staff team are motivated, undertaking relevant training and working towards their National Vocational Qualifications. Medication is generally well managed in the home with relevant procedures in place for the administration of medicines. There is good support for the home by the provider organisation, with effective monitoring and quality assurance systems in place. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 7 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. Monro Avenue (54) DS0000015064.V294846.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 Monro Avenue (54) DS0000015064.V294846.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): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. Prospective service users have the opportunity to visit the home on an introductory basis, before making a decision to move there, ensuring that service users are able to make an informed choice about where they live. EVIDENCE: The inspector looked at the admissions policy and the initial assessment tool. The assessment tool is called “Moving into Macintyre Care” and is comprehensive and detailed. Pictures are included alongside written information to enable the potential service users to understand the process. There has been one admission to the home that took place on 5th August 2005 and the inspector looked at the completed assessment for this individual. All areas of the assessment are completed and the document is signed and dated by the person completing the assessment. The home has a policy called “Moving in and Moving out guidelines”. This gives details of trial visits to the unit, day-to-day support service users can expect and details of how and when a review of the placement will occur. The Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 10 inspector observed written information contained in the assessment tool about visits this individual had made to the home, including overnight stays and weekend visits. There is evidence from the care notes that the care-plans were working documents. All specialised services offered are accessed through the Learning Disabilities Community Team and the registered manager stated that the home has a good working relationship with the team. The inspector was told that that religious and social and/or cultural needs of service users could be facilitated. Service Users are informed about independent/self advocacy groups, and examples given to the inspector of local groups were Milton Keynes Advocacy and People First. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and consistent care planning systems are in place that provides staff with adequate information they need to satisfactorily meet service users needs. Service users make decisions about their lives, with assistance and communication support, that allows them to influence their lifestyle and how the home is run. Risk assessments are in place that outline individual vulnerabilities and which contain control measures that enable service users to live their lives as independently as possible. EVIDENCE: Each service user has a personal file and care plans are kept within these. Preferred terms of address are included in service users plans. The inspector examined several personal files at random. These are informative and comprehensive, covering a wide range of needs. Information included in these is a pen picture, health check records information regarding family/friends, medical information, daily routines and likes and dislikes. There is evidence that the care plans are working documents and that changes to care plans are made when the changing needs of service users warrant it. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 12 MacIntyre Care has recently introduced a new care plan format called, “ About me and how to support me” and the home is presently completing these to replace existing care plans. These cover areas such as health and personal care, feelings and emotions, community access, managing behaviour, medical needs, day activities. These are accompanied by pictures to make the care plans more user friendly. The inspector was told that service users families are involved in the careplanning process if the service user wishes them to be. The home operates a key worker system. The home attempts to involve the service users with key decisions about their lives and provide assistance as needed. However, communication difficulties with service users can make this a complex process. The home has recently undertaken a communications project to help improve communications with service users. Communication aids have been purchased and are being implemented with individuals to enhance a better understanding. Guidelines regarding missing persons and a range of individual risk assessments are in place. Examples seen include assessments for choking, falls, using transport, use of stairs and community access. These are dated and signed and there is evidence of regular review. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can take part in age, peer and culturally appropriate activities that support and enrich service users social and educational opportunities. Service users are presented with ample opportunities for social inclusion and benefit from good staff support to do so. Staff support service users in maintaining family links and friendships inside and outside the home. Service users rights are respected and the daily routines of the home promote individual choice, providing service users with the ability to be as independent as their needs allow. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Service users learning disabilities are profound and at the time of the inspection there were no individuals undertaking educational or occupational training. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 14 Service users go out to day care activities and also have a day off in the week to undertake personal activities with the homes staff, such as personal shopping. Day care services will also visit the home to undertake activities with individuals. There is evidence in personal files that service users attend the local leisure centre, cinema, shops, bowling, health centre and local pubs and restaurants. The registered manager said that there have been no difficulties encountered with nearby neighbours. Service users do not vote, but are on the electoral role. Families and friends are welcomed into the home and are involved in daily routines and activities. Service users can choose whom they see and can see visitors in their own rooms, in private, if they wish. There are no restrictions about family and friends visiting. Staff knocking on bedroom, toilet and bathroom doors maintains the privacy of individuals. If service users express a wish to have a key to their own bedrooms then this can be facilitated. Staff open mail with the service users, as they are unable to do so themselves and the mail is read to them. Preferred term of address are used for service users and this is recorded in the care plans. Care staff seen interacting with service users do so with respect and in a manner that is appropriate to the individual. Service users are offered a choice of suitable menus. This takes the form of staff knowing what the likes and dislikes of service users are and pictures and photographs are used to assist service users to make a choice/decision. An alternative meal can be offered if the service user does not like the day’s menu. The home offers drinks and snacks throughout the day in accordance with needs of the service users. Individuals can take their meals in their rooms if they wish to. Service users are weighed regularly and this is recorded in their care plans. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. The physical, emotional and health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration of medication are generally well managed protecting service users and ensuring their medication needs are met. However appropriate training of staff regarding the administration of rectal diazepam needs to be implemented. EVIDENCE: Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 16 Information regarding personal care is recorded in the service users care plans. Service users are very dependent and staff attempt, through body language and other forms of non verbal communication to determine when service users would like to go to bed, bath, have their meals and take part in other activities. This is recorded in individual care plans. This extends to supporting service users to choose clothes, hairstyles, make up and general appearance. The unit operates a link worker system. The care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families, friends and relevant professionals outside of the unit. Service users are supported and facilitated to manage their own healthcare where practicable. Service users visit their G.P. on a needs only basis. Chiropody Services are accessed locally on a needs only basis. Additional support is accessed through the Learning Disabilities Community Team, where service users can access physiotherapists, occupational therapists, speech therapists and other specialist service they may require. Visits to the home from healthcare professionals take place in the service users bedrooms. Staff provide support to service users needing to attend outpatient and other appointments. The inspector saw evidence in care plans that eye screening is being undertaken on an annual basis. The home operates a link worker system. The care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families, friends and relevant professionals outside of the unit. Baby monitors were being used at night for two service users who have epilepsy. This is recorded in the care plans of service users. The nutritional needs of service users are identified and their weight is monitored. None of the service users in the home are able to self-administer their own medication. Several service users have epilepsy and occasionally require rectal Diazepam stesolids. There was evidence that staff receive training from The National Society for Epilepsy to do this but this is not felt to be adequate. It is a requirement of the report that training in the administration of rectal stesolids is either approved by the PCT or staff cease the practice of administering rectal stesolids. There is evidence in staff training files to show that staff have undertaken medication training via Aylesbury College. This is a distance-learning course and once completed staff receive a National Certificate in Further Education level 2. The supplying pharmacist visits the home twice a year to undertake an audit and a record of these are kept in the home. Records show all medication received, administered and leaving the home, or disposed of. It was pleasing to note that there are no omissions. No controlled drugs are in use. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective complaints procedures to ensure that service users or their representatives are listened to. Policies and procedures to protect service users from abuse are in place, including financial protection. Up to date POVA training ensures that staff have a good knowledge and understanding of Adult Protection issues that protect service users from abuse. EVIDENCE: Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 18 There is a complaints procedure dated March 2003. This is in pictorial/photo form for service users. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. This includes information on how to refer a complaint to the Commission. The unit has a dedicated book for the recording of complaints, however no complaints have been received since the previous inspection. All complaints are reviewed monthly and these are sent to the organisations central office. The home use the Milton Keynes “Protecting Vulnerable Adults from Abuse” policy and a MacIntyre Care policy called “Protecting Vulnerable Adults from Abuse” dated September 2003 There are guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. There is a public disclosure policy dated Sept 2003. Staff spoken to are aware of how to report any suspected abuse and are also aware of when it would be necessary to disclose information given to them in confidence. Following an examination of training records it was evident that staff are up to date with POVA training. There is a Whistle Blowing policy and a Physical Intervention Policy dated September 2002. The organisations policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. There is a gift procedure that provides staff with guidelines about receiving personal gifts from service users. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 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, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good, providing service users with an attractive and homely place to live. However, the flooring in the dining room, toilets and bathrooms need to be replaced to ensure they remain safe, comfortable and accessible to the people living there. EVIDENCE: Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 20 The home is a detached house reflecting the style of houses in the area. The house is clean and well decorated. Some redecoration had taken place in the lounge and dining room that has enhanced these areas of the home. The flooring in the dining room is badly stained and needs to be replaced. This is a requirement of the report. A separate quiet sitting room is accessible to service users on the upper floor. This contains the homes computer and all service users have access to this. The home offers six single bedrooms all with hand-basins. All bedrooms in the home are personalised with service users own belongings. Each room is decorated individually to suit the tastes and choices of service users. The kitchen is accessible to service users if they wish to assist with meal preparation. The home provides adequate toilets, shower and bathing areas. The flooring in the toilets and the bathrooms are worn, have come unstuck from the walls and split along the joints. To ensure these areas stay safe the flooring needs to be replaced and is a requirement of the report. Grab rails, assisted baths and other aids were observed in place throughout the home. The laundry facilities for the home are sited so that soiled washing does not come into contact with the kitchen. Hand washing facilities are sited in the laundry. The floors in the laundry were washable and the walls easily cleanable. Instructions were observed in the laundry regarding the washing of foul linen. Policies and procedures were observed by the inspector for the control of infection, which includes the safe handling and disposal of clinical waste. A tour of the home showed that cleanliness in the bedrooms and the communal areas was maintained. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 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): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective recruitment procedures in place to ensure service users are protected from harm. However, not all files held in the home contain appropriate evidence to demonstrate that all recruitments checks have been undertaken. There is a staff training and development programme that ensures staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: At the previous unannounced inspection it was decided by the organisation that documentation for staff recruitment was to be kept at a central office. However, the home must maintain a record of all persons employed at the home as detailed in Schedule 4 of the Care Homes Regulations for Younger Adults. A random selection of staff files/documentation were looked at during the visit. Not all files looked at contain evidence of references and CRB checks, copies of birth certificates or/ and passports. This will be a requirement of the report. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. Staff then complete CWPLD training. Further training for staff includes Infection Control Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 22 and Nutrition and Health which has been undertaken via Aylesbury College. Staff are then accredited with a National Certificate in Further Education level 2. Specialist training provided for care staff includes Autism and Epilepsy training. Records show that staff are up to date with mandatory training except for fire training and this has been made a requirement under Standard 42. Two care staff have completed NVQ level 2 training and one has completed NVQ level 3 training. The senior carer for the home is due to complete level 3 shortly. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of service users. The home has implemented a quality assurance system but this needs to be strengthened and delivered more consistently to ensure the home is being proactive in identifying issues that may effect the well being of services users. Overall the health and safety procedures are in place, however fire training for care staff needs to be updated and COSHH data needs to be reviewed as a matter of urgency to ensure the safety of service users. EVIDENCE: Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 24 The registered manager has been in post since 1999. She has achieved an advance certificate in management and is currently in the process of completing her Registered Mangers Award. Examples of further training undertaken by the registered manager include the safe handling of medicines, infection control, assertiveness training and nutrition and health. Staff spoken to understand and can relate to the aims and purposes of the home. This is usually achieved through regular staff meetings, staff supervision and annual appraisals. There is a communications book, handover meetings, service user plans and training. It is apparent from discussions held with the registered manager that she is not receiving formal supervision and this will be a requirement of the report. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. Macintyre Care has an equal opportunities policy in place and this is accessible to all staff. At the previous unannounced inspection carried out on 3rd January 2006 the home had recently sent out a service satisfaction questionnaire to relatives and representatives of service users. The registered manager said that only one of these had been returned. The home must ensure that they continue to explore more effective ways to provide effective quality assurance and quality monitoring systems, based on seeking the views of service users, relatives and/or representatives. The inspector requested to see Regulation 26 reports carried out since the previous inspection. However, there are no records held in the home of these since 16th January 2006. This will be a requirement of the report. Fire alarm testing is undertaken weekly and fire drills are carried out with the full involvement of the service users. A recent visit by the fire authority carried out on 14th February 2006 resulted in two areas of concern. The first was for the home to review their fire based risk assessment which had not been reviewed for two years. This has been complied with. The second area of concern was that fire training for care staff was out of date and the home must ensure that all care staff must receive basic fire awareness training on their initial induction and then annually. This must be recorded. A timescale of two months was given for this to be completed. This has not been complied with and will be a requirement of the report. The home has an infection control policy that is detailed and comprehensive. There is evidence that Health and Safety Checks are carried out quarterly and a Generic Health and Safety risk Assessment was observed. Service certificates for gas appliances are dated 11/11/05 and PAT testing was last undertaken on 16/09/04. There is an electrical installation certificate dated 16/07/04. There is evidence of water temperature recording, work placement risk assessment’s, accident and incident reports, health and safety risk Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 25 assessments and the maintenance of electrical systems and electrical equipment. Hazardous substances are stored appropriately, however COSHH sheets have not been reviewed since 2004 and this needs to be addressed. Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 26 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 X 2 3 3 3 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 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 2 X X 2 x Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 27 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 YA20 Regulation 13 Requirement The registered provider is required to ensure that training in the administration of rectal stesolids is either approved by the PCT or that staff cease the practice of administering rectal stesolids. The registered provider is required to ensure that the flooring in the dining room, toilets and bathrooms be replaced to ensure they remain safe, comfortable and accessible to the people living there. The registered manager is required to ensure that the home maintains a record of all persons employed at the home as detailed in Schedule 4 of the Care Homes Regulations for Younger Adults. The registered provider is required to ensure that the manager receives regular, recorded supervision from a line manager. The registered provider is required to ensure that visits to the home are undertaken in line DS0000015064.V294846.R01.S.doc Timescale for action 30/10/06 2 YA24 23 30/12/06 3 YA34 17 schedule 4 30/10/06 4 YA37 18 30/08/06 5 YA39 26 30/09/06 Monro Avenue (54) Version 5.1 Page 28 with Regulation 26. 6 YA42 23 The registered manager is required to ensure that all care staff must receive basic fire awareness training on their initial induction and then annually. The registered manager is required to ensure that COSHH risk assessments and data sheets be reviewed. 30/10/06 7 YA42 13 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Monro Avenue (54) DS0000015064.V294846.R01.S.doc Version 5.1 Page 30 - 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. 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