Inspection on 01/03/06 for Shakespeare Way (4)

This inspection was carried out on 1st March 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

Shakespeare Way (4) 28/01/09

Shakespeare Way (4) 20/03/08

Shakespeare Way (4) 15/08/06

Shakespeare Way (4) 01/12/05

Shakespeare Way (4) 28/02/05

Shakespeare Way (4) 25/01/05

Shakespeare Way (4) 26/03/04

Similar services:

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 Shakespeare Way (4) Aylesbury Bucks HP20 1JF Lead Inspector Mrs Gill Gentles Unannounced Inspection 1st March 2006 12:55 Shakespeare Way (4) DS0000023049.V282281.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 Shakespeare Way (4) DS0000023049.V282281.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. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shakespeare Way (4) Address Aylesbury Bucks HP20 1JF 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) 01296 426332 jackieaklippel@yahoo.co.uk www.macintyrecharity.org MacIntyre Care Miss Jaqueline Klippel Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: 4, Shakespeare Way is situated a short distance from the town centre of Aylesbury, where a variety of shops and other local amenities can be found. The town is served by local public transport, including rail and bus links. Bus routes pass within walking distance of the home. 4, Shakespeare Way is owned by the organisation MacIntyre Care. A manager is in post to carry out the day-to-day running of the home, and is supported by a team of care staff. The home provides accommodation for up to six adults with learning disabilities. The home works with service users who have developed moderate levels of independent living skills so that the role of staff is essentially one of support and guidance. All service users are accommodated in single bedrooms, and the home contains a kitchen, dining room, lounge, two bathrooms, three toilets, a staff office, and a utility room. All service users bedrooms, as well as bathrooms and toilets, have lockable doors to ensure security, privacy and dignity. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Gill Gentles carried out this unannounced inspection between 12.55 and 3 pm on Wednesday 1st March 06. The inspection process involved talking to the member of staff on duty and reading key documentation. What the service does well: What has improved since the last inspection? What they could do better: The home maintains a Person Centred Planning approach to the care provided which was found to be good; however shortfalls in failing to identify current needs could potentially put service users at risk. There was no evidence of Risk Assessments being utilised potentially putting service users at risk from harm The home is failing to maintain a current health care plan putting service users at risk. There are a number of shortfalls in handling medication which could put service users at risk. There is a shortfall in maintaining the health and safety records potentially putting service users at risk from harm. Shakespeare Way (4) DS0000023049.V282281.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. Shakespeare Way (4) DS0000023049.V282281.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 Shakespeare Way (4) DS0000023049.V282281.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): EVIDENCE: The home has not had any new service users since the last inspection. The member of staff on duty was asked for the policy relating to admission of service users but was unable to locate it. Therefore these standards were not assessed. Shakespeare Way (4) DS0000023049.V282281.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): 6, 7 & 9 The home maintains a Person Centred Planning approach to the care provided which was found to be good; however shortfalls in failing to identify current needs could potentially put service users at risk. Service users are fully involved in planning and managing their lifestyles. There was no evidence of Risk Assessments being utilised potentially putting service users at risk from harm. EVIDENCE: Each service user has a personal file which was found to contain an enormous amount of information relating to individuals. Some of the information was found to be very dated and in need of archiving. The home maintains a Person Centred Planning approach in place of an actual care plan. It was unclear as to where the plan was generated from, as there was no evidence of a Care Service Order being issued from the funding authorities. There were no clear outlines of personal support required. It is acknowledged that the service users living in this home are semi-independent and require Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 10 minimum support however this information was ascertained from the member of staff on duty and not from the personal files. The person centred approach incorporates the essential information such as contact details of family, other professionals etc. there is a very detailed pen picture written by families which clearly includes each service user’s history. There is also some exceptional work carried out with service users in relation to hopes, dreams and wishes; however there is little or no information relating to current needs. The manager must ensure that current needs are incorporated within the plan. Two files were viewed and information read was found to be clear, concise and informative about future goals and how these are being worked towards. There are regular days with the key worker and meetings monthly to re-evaluate the goals set, records are maintained to evidence these sessions. As previously stated it would be difficult for new staff to ascertain service users current needs and the support required from the information in the files which is in need of improving. Service users are clearly involved in participating and making decisions about their lives. Clear evidence was seen regarding activities chosen, meals selected and developing a more independent lifestyle. Risk assessments were found to be missing from individual files and upon request the member of staff on duty was unsure where they were maintained. The manager is reminded that all service users must have specific Risk Assessments in place pertinent to their lifestyles to reduce the risk of hazards identified and to promote independence. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 Services users are supported and encouraged to be involved in the daily routines of the home, promoting personal independence and growth. The home provides a supply of nutritious and balanced foods ensuring services users are supported and encouraged to maintain a healthy diet. EVIDENCE: Services users are encouraged to be involved in the daily routines of the home, staff support independence and promote individual choices. Entrance into resident bedrooms and bathrooms only occurs with the individuals permission and normally in their presence maintaining privacy and dignity for all service users. Services users are encouraged to undertake some responsibility for getting involved in the cooking and cleaning of the home. The staff promote a nutritious, balanced and varied diet. Breakfast and lunchtime meals (depending on where service users are during the day) are taken as and when required with a range of drinks and snacks being readily available throughout the day. The evening meal is prepared for everybody in the home. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 12 Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 13 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): 19 & 20 The home is failing to maintain a current health care plan putting service users at risk. There are a number of shortfalls in handling medication which could put service users at risk. EVIDENCE: The two service users files perused had information relating to healthcare; however upon perusal it was very clear that this information was very dated in fact as far back a 2003. there was no evidence of any current health care needs being identified. This links in with the home not identifying current personal support needs as previously stated in standard 6. The manager is required to ensure that each service user has a current health care plan in place. The home stores medication safely and securely. Medication is received from Boots the chemist on a monthly basis in blister packs or for creams and lotions in the original containers. However, shortfalls were identified: • Medication Administration Records indicated “G” as a code but there was no information to explain why. • No PRN protocol for as and when required medication e.g. paracetamol. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 14 • • Over the counter “homely remedies” are in use without written consent from the GP to confirm that it is safe to use with prescribed medication. Creams and lotions not dated when opened as there is a limited shelf life when opened to the elements. The manager must ensure that these issues are rectified to ensure safe handling and administering of medication is taking place. The member of staff on duty confirmed that all four staff have completed the ASET medication training and are awaiting confirmation of whether they have passed or not. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 15 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): These standards were not assessed during this inspection. EVIDENCE: Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 16 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): These standards were not assessed during this inspection. EVIDENCE: Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 17 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): EVIDENCE: It was not possible to access recruitment records as these are held centrally at Macintyre’s head office in Milton Keynes. The Commission’s Regulation Managers are visiting the Human Resources department in March 06 to inspect a cross section of personnel records. Training records were also unavailable as the manager was on a course at the time of the inspection. However, the member of staff on duty confirmed that during her six months of employment she has attended infection control and healthy eating training and completed the medication training by ASET. She is also working her way through her induction known as PDP and the CWPLD (old L’DAF). There was no confirmation that she or any members of staff have attended the mandatory training during the past six months. The manager is required to forward a copy of the up to date training matrix for the four staff employed in this home to the Commission. Shakespeare Way (4) DS0000023049.V282281.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): 39, 42 Monthly proprietors visits are carried out unannounced ensuring service users views are ascertained about the service. There is a shortfall in maintaining the health and safety records potentially putting service users at risk from harm. EVIDENCE: The home maintains a file that contains Regulation 26 reports which are carried out monthly by Christine Harvey. The last three months were viewed and found to contain information about documents read, feedback from staff and service users and a summary of the findings per visit. The manager ensures the health, safety and welfare of service users and staff are adhered to. Good records are maintained and appropriate checks carried out in relation to fire, COSHH and Portable Appliance testing. Water temperature are recorded and records indicate that the hot water in some areas is reaching as high as 54.6°c. There was no evidence that the annual Gas safety check had been carried out. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 19 The manager is required to ensure that all the health and safety services take place annually as and when required. Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 20 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 2 X X X 3 X X 2 X Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 21 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 Standard YA6 Regulation 15(1) Requirement The manager must ensure that current needs of service users are incorporated within the care plans. The manager is required to ensure all service users have Risk Assessments in place pertinent to their lifestyles to reduce the risk of hazards identified and to promote independence. The manager is required to ensure that each service user has a current health care plan in place. The manager must ensure that medication shortfalls identified in the main body of the report are rectified to ensure safe handling and administering of medication is taking place. The manager is required to forward a copy of the up to date training matrix for the four staff employed in this home. Timescale for action 31/05/06 2 YA9 13(4) 31/05/06 3 YA19 15(1) 31/05/06 4 YA20 13(2) 15/04/06 5 YA35 18(1)(a) 30/03/06 Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 22 6 YA42 13(4) The manager is required to ensure that all the health and safety services take place annually or as and when required. 30/03/06 7 YA42 13(4)(a-c) The manager must ensure that the hot water is regulated appropriately with either the installation of thermostatic valves or by ensuring they are working properly. 31/05/06 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. 2. Refer to Standard YA37 YA41 Good Practice Recommendations That any temporary changes to managerial arrangements in the home are formally notified to CSCI That reports of visits conducted under Regulation 26 are readily available for scrutiny at all times Shakespeare Way (4) DS0000023049.V282281.R01.S.doc Version 5.1 Page 23 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 Shakespeare Way (4) DS0000023049.V282281.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. 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!