Inspection on 03/01/06 for Monro Avenue (54)

This inspection was carried out on 3rd 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

Monro Avenue (54) 18/02/09

Monro Avenue (54) 12/03/08

Monro Avenue (54) 01/08/06

Monro Avenue (54) 31/03/05

Monro Avenue (54) 01/11/04

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Fairways

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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 3rd January 2006 12:00 Monro Avenue (54) DS0000015064.V276164.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 Monro Avenue (54) DS0000015064.V276164.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. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 3 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.V276164.R01.S.doc Version 5.1 Page 4 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. 11th and 12th July 2005 Date of last inspection Brief Description of the Service: 54 Monro Avenue is a small residential care home registered to provide care for up to 6 adults with Learning Disabilities. It is situated in a residential area of Milton Keynes and provides a domestic environment for service users. It is a two storey building in style similar to nearby properties. Accommodation is in single rooms with a shared sitting room and dining room and kitchen. There is an accessible and safe garden to the rear of the property.The home is owned and managed by Macintyre Care. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 3rd January 2006 at 12.00pm. The visit consisted of discussions with the manager and records, policies and procedures were examined. The inspection officer was Barbara Mulligan. The Registered Manager of the home is Nickie Croucher. What the service does well: What has improved since the last inspection? What they could do better: Staff files, or evidence of appropriate recruitment procedures are not available in the home for newly appointed staff members. This is a requirement of the report. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 6 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.V276164.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 9 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): These standards were not assessed during this inspection. EVIDENCE: Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed during this inspection. EVIDENCE: Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 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): These standards were not assessed during this inspection. EVIDENCE: Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 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): 22 and 23. The home has effective complaints procedures to ensure that service users or their representatives are listened to. Staff have a good knowledge and understanding of Adult Protection issues which protect service users from abuse. EVIDENCE: There is a complaints procedure dated March 2003. 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 home has a dedicated book for the recording of complaints. The home has received no complaints since the previous announced inspection. All complaints are reviewed monthly and sent to the central office and the inspector saw evidence of this. 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 receive training about Adult Abuse and this forms part of their induction. There is a Whistle Blowing policy and a Physical Intervention Policy dated September 2002. The homes policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 13 guarded. There is a gifts procedure that provides staff with guidelines about receiving personal gifts from service users. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 14 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 The standard of the environment within this home is good, providing service users with an attractive and homely place to live. Standards of cleanliness at the home are good ensuring that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: The home is situated in the Crown Hill area of Milton Keynes. It is a modern, purpose built home built in the style of the surrounding homes. There is good access to local facilities and the home appeared well maintained, clean and nicely decorated on the day of inspection. Communal areas are comfortable, bright and cheerful. Following a requirement made at the previous unannounced inspection the home has recently had a new fitted kitchen and this has improved access for service users to the kitchen. 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 are easily washable and the walls easily cleanable. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 15 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 home is well maintained. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Service users benefit from clarity of staff roles and responsibilities that results in a good quality care service being delivered. Service users benefit from a staff team who are appropriately trained to ensure that service users are cared for by skilled staff at all times. Staffing levels are good and as a result service users receive consistent care. There are effective recruitment procedures in place to ensure service users are protected from harm, however there is no information available for the two newly appointed care staff as these are now stored at a central office. This does not make them available at all times for inspection purposes. Service users benefit from having staff who are supervised and whose performance is appraised regularly. EVIDENCE: Rotas demonstrate that appropriate levels of staff are on duty across a twentyfour hour period. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 17 A random selection of staff files were looked at during the visit. A request was made to look at files of the most recently employed care workers. The inspector was informed that all documentation for these individuals are kept at a central office and this is to be the practice of the organisation. Evidence of employment checks still needs to be available in the home and will be a requirement of the report. Staff meetings occur on a regular basis and minutes are kept of these. All care staff receive an annual appraisal and training needs are identified during staff supervision. Staff supervision is carried out on a monthly basis. There are no staff members under the age of eighteen and there are no staff under twenty one left in charge of the home at any time. All staff receive an induction programme relevant to the organisation. This covers equal opportunities training, disability equality training and race equality training. Further induction is carried out that includes fire safety, moving and handling techniques and core skills training. Progress is being made with NVQ training. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 18 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, 39, 40, 41, 42 and 43. 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. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Various methods of measuring quality assurance are in place ensuring that the quality standards that apply to service provision are maintained to a prescribed standard and, in relation to service users requirements, are not compromised. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 19 EVIDENCE: The head of service has been in post since 1999. She is currently in the process of completing her Registered mangers award. Examples of further training undertaken by the head of service include POVA Training, Food and Nutrition, Autism, Epilepsy and managing Disciplinary hearings, absence and sickness. Staff 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. 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 was looked at during the inspection. The home has undertaken a service satisfaction questionnaire that was sent to relatives and representatives of service users. She stated that only one of these was returned to the home. Regulation 26 reports were available for inspection. All policies and procedures are kept in the office and are accessible to all staff working in the home. Staff are encouraged to read the homes/organisations policies. There are no policies available in different formats for service users and it is recommended that the registered provider give serious consideration to this. If service users wish to look at their own records then this can be facilitated by the home. Records and home records are noted to be up to date, stored securely and in good order. All records seen are constructed, maintained and used in accordance with the Data Protection Act 1998. Fire alarm testing is undertaken weekly and fire drills are carried out with the full involvement of the service users. 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 11/11/2005 and PAT testing was last undertaken on 16/07/04. There is evidence of water temperature recording, work placement risk assessments, accident and incident reports, health and safety risk assessments and the maintenance of electrical systems and electrical equipment. Hazardous substances are stored appropriately and the COSHH sheets were looked at. These are up to date. There are insurance certificates on display in the home. The organisations business and financial plan was not available for inspection. Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 20 Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 21 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 X 3 X 4 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x 3 3 3 3 3 3 3 Monro Avenue (54) DS0000015064.V276164.R01.S.doc Version 5.1 Page 22 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. 1 Standard 34 Regulation 17 Requirement The registered manager is required to ensure that evidence is available of all recruitment checks undertaken by the organisation for care staff working in the home. Timescale for action 30/01/06 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.V276164.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Aylesbury Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR – 01296 737550 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.V276164.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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