Inspection on 15/08/06 for Shakespeare Way (4)

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 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) 01/03/06

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 Mr Rob Smith Unannounced Inspection 15th August 2006 10:30 Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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.V301318.R01.S.doc Version 5.2 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.V301318.R01.S.doc Version 5.2 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.V301318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 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 run MacIntyre Care who are a well established provider of a range of day and residential care services for adults and young people with learning disabilities. 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, rather than direct provision of care. The home comprises two linked semi-detached properties that offer single bedrooms to each service user, along with communal lounge, kitchen, dining and laundry areas. At the time of this inspection there were five service users in residence. Fees for placements at the home currently ranged from £37,292 to £40,390. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted from 10.30 a.m. to 3.30 p.m. It comprised the following activities: • Consideration of pre-inspection questionnaires submitted by all current service user and comment cards submitted by professionals supporting the home Consideration of pre-inspection information and self-assessment forms submitted by the manager Discussion during a site visit with the manager and other staff on duty. Discussion with one service user Tour of the premises Examination of a sample of establishment and service user records. • • • • • Verbal feedback was given to the manager during the course of the site visit. What the service does well: What has improved since the last inspection? The management of medication and pharmacy support arrangements had improved. Records maintained of staff training were more comprehensive. Systems for ensuring safe water temperatures had improved. The garden area had been redesigned to the wishes of service users. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 6 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. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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.V301318.R01.S.doc Version 5.2 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): 1&2 Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. Appropriate systems were in place to provide relevant information and ensure any potential admissions to the home had their needs assessed appropriately. EVIDENCE: No new admissions had taken place since the last inspection, or indeed for some time, so direct evidence of the management of new admissions was not available for scrutiny. However discussion with staff and the manager confirmed that any new admissions would receive a full assessment by senior staff before consideration of placement and that introductory visits and overnight stays would take place prior to any final placement decisions. The views of existing service users would also be taken into account. Two referral assessments had apparently been undertaken recently but had been forwarded to external senior managers for consideration so could not be inspected on this occasion. The blank format for assessment was seen and covered appropriate initial areas for consideration. Written information on the home was available in the service user guide and the statement of purpose, both of which were in need of some minor updating to take account of changes to the house. A recommendation has been made to address this point. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 9 Although all the appropriate elements appeared to be in place, the home did not have any formally documented referral and admission policy and procedure that laid out clearly all the steps that would be gone through. As a matter of good practice, and to conform with the expectations of Appendix 2 of the National Minimum Standards, this should be drawn up to ensure clarity and consistency of practice. A recommendation has been made to address this point. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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, 7 & 9 Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. Individual plans and related personal needs information was still not fully up to date and therefore risked current service user needs being overlooked. The way in which the home worked ensured service users were able to make significant input into decisions about the way their care was provided. Service users were supported to take suitable levels of risk to maximise their independence. EVIDENCE: The last inspection had identified a series of shortfalls in the provision of up to date and accurate care plans and information about service user care needs. Discussion with the manager, and examination of a sample of files, indicated that although an updating process had started, for example in weeding out old outdated file information, progress had been slow, so that the situation was largely unchanged with regard to the majority of service users. It was evident from being in the home, and from talking with staff, that they were all Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 11 conversant with service users’ current needs and the structure for the personcentred plans, into which service users evidently had significant input, was satisfactory. However this approach must be more fully reflected in up to date written plans and information held on files to ensure current care needs are clearly and unambiguously identified and consistently met. A repeated requirement has been made to address this issue. The home worked well to meet the diverse needs of the resident group. None currently came from a minority ethnic or cultural background, but their needs in terms of support around their disabilities and their differing personal situations and aspirations were well understood by staff and appropriately met. The team worked particularly hard to ensure integration into normal community experiences and to challenge inappropriate attitude and discrimination faced by service users. Discussion with staff, observation of practice with one service user and feedback in service user questionnaires all confirmed that the home worked very well at ensuring service users were able to play the key role in determining how their care was arranged, and in how their plans for the future were determined. This applied to individual decisions around areas such as activities, holidays, diet, bedroom decoration etc as well as more ‘house’ related decisions such as, for example, the recent makeover of the back garden area, which had come about largely at the request and design expectations of service users. Service users played a major role in their care reviews and largely determined the future planning for their long-term care. One service user was for example in the process of moving into new shared accommodation with his partner. Service users were encouraged and supported by staff in pursuing as normal a lifestyle as possible, which involved the considered taking of risk on a day-today basis. Service users were, for example, free to go out and about in the local community and to Aylesbury on their own and to take relevant levels of responsibility for withdrawing and managing their own money and spending. At times service users were also left alone in the house for short periods without staff supervision. Risk assessments were in place to address the areas of risk undertaken and staff were alert to the particular vulnerabilities of their service user group. For example, while access to a mobile phone when out and about on their own was considered potentially useful for service users, this had not yet been introduced because of the risks posed by possible theft by a local group of anti-social youths. There was evidence on the risk assessment and service user files that generic and individual risk assessments had been regularly reviewed in the past, but some were now up to a year or so since the last review. The manager indicated that a new risk assessment format was being introduced by MacIntyre and the intention was to review existing assessments at the point of this introduction. The manager also indicated that as part of the general sorting out of Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 12 information for staff all risk assessments would be held in one readily accessible central file – a development the inspector agreed was a good idea. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. The staff team provided good support for service users to ensure they undertook activities relevant to their age, abilities and interests. The lifestyles and opportunities for activities for service users ensured they were able to be part of the local community. The home worked hard to ensure service users were able to maintain appropriate family and personal relationships. The ethos of the home was based on active promotion of service user rights and responsibilities. The arrangements for meals helped encourage service users to follow a healthy diet. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 14 EVIDENCE: Scrutiny of service user files and their questionnaire feedback confirmed they were well supported by the home and MacIntyre in pursuing appropriate activities. All the service users attended MacIntyre day care services in Milton Keynes during the week, which offered opportunities in different areas (garden centre coffee shop, bakery etc) to work with other people and meet the public in constructive employment roles. Leisure time activities were appropriately varied according to service user interests. The service users made use of all relevant local community facilities as part of their everyday lives and recreational activities. Evidence of this was seen in relation to records of activities, care plans, reviews notes and discussion with one service user about his recent range of holiday activities. Service users had varying levels of contact with their families depending on circumstances, and their own wishes. A number regularly visited and stayed with family members or went on holiday with them. They had ready access to the telephone to maintain contact and staff confirmed family members were free to visit at all reasonable times. There was good evidence of support for personal relationships, with the example of one service user whose partner regularly stayed over at the home. MacIntyre placed emphasis on respecting service users’ rights in its general policies and procedures and in its service undertakings to service users. Practical evidence of this was seen in the home, in the degree of influence service users had to determine how their lives were organised, the respect for privacy and confidentiality and, for example, by the consideration given by staff to the impact of the behaviours of a past resident on service user’s quality of life in the home. This was balanced by reasonable expectations that service users exercise responsibility in terms of helping keeping the home clean and tidy, sharing meal preparation responsibilities and generally considering the needs of others in the home. Staff advised and supported service users in the drawing up of menus, purchasing of foodstuffs and preparation of meals. The menu in use at the time of this visit showed a reasonable range of healthy eating options and reflected individual preferences where relevant. No particularly complex dietary needs were present at the time of this inspection so the emphasis was on development of healthy eating habits, where staff balanced their focus on health with service users’ own perceptions of what they wanted to eat. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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 & 20 Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. The staff team provided and arranged support for service users in appropriate ways to ensure their needs were met. The emotional and healthcare needs of service users were well met Medication was managed in ways that ensured the safety of service users. EVIDENCE: The service users needed minimal direct input from staff to manage most aspects of day to day living. Support was therefore aimed at primarily at guiding and developing service users in acquiring life skills and creating and sustaining fulfilling and satisfying work and leisure opportunities, alongside monitoring of their general health and welfare. Each service user had an identified linkworker on the staff team who provided opportunities for ‘at home’ days to offer individual help and support in whichever areas were needed or wished by the service user. Service user questionnaires indicated satisfaction with the level of support provided. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 16 There was evidence that appropriate input and support was provided from other sources where relevant. One example was advocacy support for one service user to assist in thinking through a possible move on from the home to a more independent setting. Consideration was also being given to future input of bereavement counselling, and speech and language therapy input had been arranged to improve the consistency and quality of staff approaches to communication with service users. The staff team displayed in discussion good awareness of health care needs and these were generally well documented in service users’ records, although, as with overall care plans, the updating and sorting out of file information remained a task to be completed. A new structure for health care planning and record-keeping was being introduced across MacIntyre and one of these was almost complete for one service user. In theory these new health plans will improve the planning and management of health care issues and so should be a priority for completion by staff for all service users in the home. Quality in this outcome area is good. A recommendation has been made to address this point. Service users were registered with local GPs, dentists, opticians etc and records indicated regular checks were being undertaken. Other health needs were addressed as they arose, an example being the attendance of one service user at the doctor’s on the day of this inspection visit. Medication was being stored appropriately and the range of points highlighted at the last inspection had now been addressed. The home had established a contract with a new pharmacy, which the manager indicated, would provide more consistent support and monitoring of practice. Staff had completed a distance learning package on medication management and further training was planned. Medication records were maintained satisfactorily and detailed information was maintained for each service user about their medications, allergies, intolerances etc. Staff retained the primary responsibility for ensuring medications was taken as and when required by service users. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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): Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. MacIntyre had well established complaints systems in place to ensure the concerns of service users and other interested parties were listened to and addressed. Appropriate procedures, training and safeguards were in place to minimise the likelihood of service users suffering abuse or exploitation. EVIDENCE: MacIntyre care had formal complaints processes in place that could be used by service users, or by others on their behalf. No formal complaints had been made through this system and none had been made directly to CSCI since the last inspection. At a less formal level the manager also kept records of issues that had arisen and were resolved within the home itself. Five such complaints had been raised by service users over a range of relatively minor issues since the last inspection and appeared to have been resolved appropriately. This reflected the confident feedback in service user questionnaires that they would raise any concerns they had about their care directly with staff in the home. MacIntyre had detailed policy and guidance on adult protection and management of abuse concerns that had been deemed satisfactory by central senior CSCI staff. Staff received adult protection training as part of their induction and NVQ training. Training records indicated that additional specific training had also been provided. Staff in the home had also undertaken child protection training which, although focusing on a different clientele, was good Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 18 to see, as many of the protective principles and processes were transferable to adult setting. No adult protection concerns had arisen since the last inspection. Service user finances were well documented, with clear evidence of transactions undertaken by service users, and by staff on their behalf, and receipts kept. The sample finances checked were found to be accurate. There had been no incidents of challenging or aggressive behaviour in the home since the last inspection. The manager confirmed that one former resident, who had temporarily moved on from the home last year for further assessment in relation to his challenging and aggressive behaviour, would not be returning. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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 & 30 Quality in this outcome area is excellent. This judgement was made using the available evidence including a visit to this service. The home was very well maintained and continuing improvements ensured service users were provided with a good quality, comfortable and safe environment in which to live. EVIDENCE: Although in the throes of office reorganisation, which led to some inevitable untidiness on the day of this visit, the home remained very well looked after. Communal areas were attractively and comfortably decorated and well equipped. The home’s toilets and bathrooms had been modernised to a good standard over the course of the last year. As already noted major improvements were being made to the back garden in line with service user wishes. Service user bedrooms were not seen on this occasion but previous inspections consistently confirmed they were well decorated and equipped and highly personalised to individual service user tastes. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 20 The home was clean and hygienic throughout the communal areas and bathrooms. The only physical problem with the house appeared to be the long-running problem staff faced in getting a small number of missing/loose roof tiles fixed by the housing association which owned the property. As the manager appeared to have had little success in achieving a positive outcome this is perhaps now a matter for senior MacIntyre managers to pursue. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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): 32, 34 & 35 Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. The staff team was appropriately competent and qualified to meet service user needs. Recruitment procedures were designed to ensure only appropriate people were appointed to work in the home. Training support for staff was very good ensuring they were suitably equipped to meet service user needs. EVIDENCE: The staff team was unchanged since the last inspection and had continued to develop its detailed knowledge of the service users’ needs and aspirations. Of the four main team members two were qualified to NVQ level 3 and one to NVQ level 2. The remaining team member was due to commence NVQ 2 on completion of her initial learning disability initial training framework. As no new staff had been employed at the home for over a year recruitment records were not checked on this occasion. Past inspections have confirmed that written recruitment policies and procedures are in line with relevant statutory expectations. The manager informed the inspector that MacIntyre Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 22 was implementing a new system for staff recruitment information, which would enable maintenance of key information on staff appointments at the home, with original documentation being stored at MacIntyre central personnel offices. A sample of the form to be used was seen by the inspector and appeared to cover appropriate information areas, as well as incorporating scope for recording staff training undertaken. It was noted from information supplied by the manager that CRB disclosures for the manager and one other member of staff were now almost three years old or more. As a matter of good practice CSCI advises renewal of CRB disclosures every three years. Training records provided by the manager indicated that staff continued to undertake a wide range of relevant training. This focused not only on core care issues but covered in the last year, for example, subjects such as health and safety, risk assessment, bereavement, manual handling, autism, and link working. This is a commendable range of training provision and uptake by staff. Training records were being maintained by the manager and, as noted above, new formats were being introduced by MacIntyre to capture this information more consistently on staff records on the home. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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 & 42 Quality in this outcome area is good. This judgement was made using the available evidence including a visit to this service. The manager was suitably experienced and carried out her role appropriately to ensure the home was run effectively. The views of service users and other relevant stakeholders informed the running and development of the home. Good attention was paid to ensuring the health and safety of service users and staff was safeguarded. EVIDENCE: The manager was suitably experienced in the care of adult with learning disability and had been working at the home for many years at both junior and senior levels. Training records indicated the manager undertook relevant updating training in various areas of practice and management responsibilities. The manager had not yet however achieved a recognised management Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 24 qualification. She had been undertaking an NVQ4 management qualification but apparently various problems with the NVQ training provision had arisen, leading to a disrupted and much delayed process of qualification. While this was evidently beyond the control of the manager, and MacIntyre, the achievement of a relevant management qualification should now be a priority for the manager, with MacIntyre’s support, to achieve as soon as possible. Discussion with the manager confirmed there were various key elements of a comprehensive quality assurance programme in place, including regular formal feedback from service users and their families. Feedback was not regularly being sought from placing authorities at present. Although these authorities often had limited involvement with placed service users extension of formal feedback on their perspectives of the quality of care offered would add an important extra element to the service’s processes of self-evaluation. The need for a more robust and better evidenced approach to development of service improvement plans based on the information drawn from the various elements of quality monitoring already in place was also emphasised to the manager. It should be noted that as the manager played a full role on shifts she was in touch with and observing key aspects of day-to-day practice on a regular basis. The manager confirmed that regular monitoring visits were carried out by the external line manager for the home. However there were no copies of the reports following such visits available in the home. Without such a record the inspector questioned the impact of the visits and the ability of the manager to ensure consistent responses to any issues raised. The manager was advised that copies of the outstanding reports must be obtained and maintained more consistently in the home in future. Comprehensive policies and procedures were in place to address health and safety matters in the home. One senior member of staff took lead responsibility for this area of practice but all staff had undergone some form of training in health and safety, food hygiene, first aid and risk assessment. Regular overall health and safety checks were undertaken in the home and monitored by MacIntyre centrally. Water temperatures were controlled by thermostatic valves and addition regular checks of their efficiency were undertaken. Service user understanding of hot water risks were also regularly re-assessed. Some slightly high temperatures had been noted and the home was seeking a service of the valves to correct this. Fire safety was well covered with regular systems checks and servicing carried out. A fire risk assessment was seen on file and fire drills were recorded as having taken place this year, the latest being in April 2006. Another should be undertaken in the near future. Records indicated fire safety instruction had been provided for staff in July 2006. The fire service had, according to records in the home last inspected in 2002 and had been satisfied with fire safety Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 25 arrangements at that time. The home was actually contacted on the day of this inspection to arrange a new fire officer visit, which will ensure more up to date and expert assessment of fire safety matters. Generic risk assessments covering health and safety matters were in place along with information on management of hazardous materials. AS noted earlier a number of the risk assessments were over a year old and would benefit from revisiting once the new MacIntyre risk assessment forms and process are introduced. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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 3 2 3 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 X LIFESTYLES Standard No Score 11 3 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 3 X 3 X 3 X X 3 X Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 Page 27 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 That the manager ensures all care plans and other related individual care needs information in brought up to date for all service users. Repeated requirement That MacIntyre Care ensures reports of monitoring visits undertaken under Regulation 26 are always drawn up and copies made consistently available for inspection in the home. Timescale for action 31/10/06 2 YA39 26 31/10/06 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 3 Refer to Standard YA1 YA4 YA42 Good Practice Recommendations That the manager ensures the statement of purpose is updated to reflect recent changes in facilities provide by the home. That the manager ensures a formal written admission procedure and process is drawn up. That the manager ensures all generic and individual risk DS0000023049.V301318.R01.S.doc Version 5.2 Page 28 Shakespeare Way (4) 4 5 6 7 8 YA19 YA24 YA34 YA37 YA39 assessments are brought up to date. That the manager ensures individual health care needs and information relating to service users is brought up to date as part of the introduction of the new health care plans. That MacIntyre Care pursues with the property owners the longstanding delays with roof tile repair. That MacIntyre Care ensures that CRB clearances are renewed on a three yearly basis. That MacIntyre Care supports the manager of the home in completion of her management qualification. That the manager ensures that a more structured approach is adopted to the development of service improvement plans. Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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 Shakespeare Way (4) DS0000023049.V301318.R01.S.doc Version 5.2 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. 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