Care Home: Haddon (42a)

Similar services:

• Hillview Farm
• Dalewood Respite Care
• Orchard,The
• REACH Upton Court Road
• Fairways
• Treloar College
• Kestrel House, St Anne`s Opportunity Centre,
• Pinta

What the care home does well The flats are a nice and comfortable place to live.People who want to live Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 6at Great Holm have their needs assessed before they move in, to make sure the staff can meet the needs of the people who live there. The care plans tell the staff how to care for the people living in the flats. The staff makes sure that the people who live in the flats are safe when they go out and take part in activities. The people who live in the flats are good friends.The service provides good healthy meals for all the people who live there.People who live at Great Holm are helped to visit the Drs and other health care staff. What has improved since the last inspection? Regular staff working in the home have had up to training.People are no longer at risk of being burnt by hot water.Decoration and repairs have been made to the flats to make them safe and homely. The home safely looks after the money and belongings of the people who live there. What the care home could do better: This inspection shows that 2 things need to be done to make it okay.Staff know how to keep the people living at Great Holm safe, but the policy for protecting people needs to be updated.FIREAll staff must have regular fire training to keep people who use the service safe. CARE HOME ADULTS 18-65 Haddon (42a) 42a Haddon Great Holm Milton Keynes MK8 9HP Lead Inspector Barbara Mulligan Key Unannounced Inspection 21st January 2008 10:00 Haddon (42a) DS0000028414.V357881.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 Haddon (42a) DS0000028414.V357881.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. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haddon (42a) Address 42a Haddon Great Holm Milton Keynes MK8 9HP 01908 262860 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 Karen Campbell Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 Brief Description of the Service: Set on the edge of Great Holm, no.42a Haddon, owned by Macintyre Care, is located within a campus style complex, in amongst private housing. It provides accommodation to adults with learning disabilities. 42a Haddon is situated within walking distance of the local shops, church and local pubs. The building itself contains five self contained flats and a small garden area. There is a further complex of buildings that comprise of no. 52a and no. 32a Haddon, the organisations day care services, a hall, a nursery and garden centre, a craft shop, a coffee shop, bakery and an administration office. The coffee shop and bakery occupy the corner of the site and this provides occupational opportunities for service users and enables local residents to visit the shop. The nursery, garden centre and craft shop also provide occupational activities for service users and are open to the public. 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. Service users are encouraged and supported to use public transport to which they have access. Fees range from £ 22,000 to £39,000 per year. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was conducted over the course of a day and covered allof the key National Minimum Standards for younger adults. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. No comment cards were received from people who use the service by the time the report was written. The inspection officer was Barbara Mulligan. The registered manager is Karen Campbell. The inspection consisted of discussion with the registered manager and other staff, opportunities to meet with some service users, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Twenty-five of the National Minimum Standards for Younger Adults were assessed during this visit. Twenty-three these are fully met and five are almost met. As a result of the inspection the home has received two requirements. 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. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: The flats are a nice and comfortable place to live. People who want to live Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 6 at Great Holm have their needs assessed before they move in, to make sure the staff can meet the needs of the people who live there. The care plans tell the staff how to care for the people living in the flats. The staff makes sure that the people who live in the flats are safe when they go out and take part in activities. The people who live in the flats are good friends. The service provides good healthy meals for all the people who live there. People who live at Great Holm are helped to visit the Drs and other health care staff. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? Regular staff working in the home have had up to training. People are no longer at risk of being burnt by hot water. Decoration and repairs have been made to the flats to make them safe and homely. The home safely looks after the money and belongings of the people who live there. What they could do better: This inspection shows that 2 things need to be done to make it okay. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 8 Staff know how to keep the people living at Great Holm safe, but the policy for protecting people needs to be updated. FIRE All staff must have regular fire training to keep people who use the service safe. 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. The summary of this inspection report can be made available in other formats on request. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 9 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 Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. People who use the service have their needs thoroughly assessed prior to admission ensuring that staff are prepared for admission, and given opportunity to visit the home beforehand to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have not been any new admissions to the service since 2005, according to information supplied prior to the inspection. However, each person using the service has a comprehensive needs assessment on file, which demonstrates that they have been involved in this process. The home does not take emergency admissions and is not registered to provide intermediate care. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Detailed care plans are in place, which adequately documents the care needs of people who use the service, and how these are to be met, within a risk assessment framework. People who use the service are enabled to make decisions and be as independent as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of four people using the service was case tracked and their care plans were examined. Each file contains various care planning tools. For example each file contains the an “Essential Lifestyle Plan” which is the corporate care plan tool, an “intimate care policy”, a “health care plan, and a Person Centred Plan. Although this ensures that a lot of information is in place, there is a lot of duplicated information. A reduction of unnecessary information would make the care plans more user friendly and is recommended. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 12 The care plans examined by the inspector provide detailed guidance for staff to follow and are detailed and informative. However, the intimate care policies are out of date and contain differing information to the Essential Lifestyle Plan. For example, in one intimate care policy it states that the person using the service does not need support when taking a shower or bath. However, in the up to date Essential Lifestyle Plan it records that the individual requires support to wash their hair every other day when in the shower or bath. It is questionable if the intimate care policies are necessary, because the information required regarding personal care is contained with the Essential Lifestyle Plan and this is reviewed regularly. The registered manager has added extra sections to the Essential Lifestyle Plan that include healthcare, leisure and social needs. This again means that healthcare needs are documented twice, once within the health care plan and again in the essential lifestyle plan. Person Centred Plans are still being developed and demonstrate that service users and families and friends have been involved in these. Photographs of the individual are placed at the front of their files with information on their history. Copies of local authority community care plans and purchase orders were seen to be in place. Flat meetings are held between people who use the service and staff, to share and discuss any issues and pass on news. Minutes are kept of these and demonstrate that issues raised are managed appropriately. The registered manager said that link worker meetings, called “my meeting” are held with people using the service on a monthly basis. Minutes are kept of these meetings and were seen in individual files. These demonstrate that agreed actions are taking place to meet care needs. Additionally, a fortnightly people’s forum takes place, facilitated by an independent person which is open to all people who use the MacIntyre services at the Great Holm site. People who use the service were seen to make decisions during the inspection, such as what to make for lunch, what to buy at the shops and arranging evening activities. Money is well managed for people who live at Great Holm. There are individual wallets kept secure and transaction sheets to record expenditure. Receipts are in place to verify purchases. Reports of the provider’s monitoring visits show that service users’ money is checked routinely as part of the visit, which is a good practice. Risk assessments were observed to be in place and these are signed and dated by the author. All of these show that they are reviewed and updated regularly. Examples of risk assessments seen include bathing, horse riding, using hot water, cooking and falls. Missing person procedures are in place in the event of anyone being absent from the home without notice and for staff to refer to, if need be. Haddon (42a) DS0000028414.V357881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. People who use the service have a varied and active lifestyle, which reflects their interests, and are supported to maintain family links and friendships inside and outside the home. Menus are developed by people who use the service with support from care staff that promotes independence and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was told that people who use the service are involved in a number of activities, which are locally based at Great Holm, where there is a coffee shop, a craft shop and a nursery. On site there are opportunities for individuals to take part in craft, drama and computer classes. There is also opportunity for those that wish, to develop office skills and undertake a National Vocational Qualification working at the provider’s central headquarters. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 14 Records show that service users’ interests are taken into account when organising activities for them, whether as part of the day service provision or when at home. Examples seen include pottery, bakery, music, catering, a book club and Drama. Care plans show the leisure activities that people who use the service are able to take part in. Examples seen include the local leisure centre, a local gym, cinema, shops, library, health centre and local pubs and restaurants. Many local residents and members of the public visit the coffee shop where people who use the service are employed, and staff support individuals to become part of, and participate in, the local community. The inspector was informed that relations with the neighbours were positive and that there had been no problems encountered. Care plans show that people who use the service have access to transport and use taxis, buses, dial-a-ride and trains. People who use the service choose to vote and do so by proxy or by attending the local polling station on voting day. People who use the service were seen to have keys to their doors and had freedom to be alone in their rooms or in the communal areas. In discussions with people who use the service it is apparent that there are no restrictions about family and friends visiting. One person using the service told the inspector that they have a mobile phone to call family and friends. The registered manager informed the inspector that service users can chose whom they see and when, and can see visitors in their rooms and in private. On the day of the inspection one individual was going to have dinner with their friend in another flat. Each flat that was seen had its own menu drawn up by people who use the service and individual needs such as healthy eating are being met. Monthly weights are recorded in a separate book and nutritional screening is evident in files. Haddon (42a) DS0000028414.V357881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. Personal and healthcare support for people who use the service is good and the systems for the administration of medication are generally well managed, protecting service users and ensuring their personal and healthcare needs are appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information regarding personal care is recorded in the Essential Lifestyle Plans. People who use the service are supported to choose when they like to go to bed, have a bath, have their meals and take part in other activities. Care plans set out in detail peoples preferred routines, likes and dislikes and partnerships with families and friends. Staff ensure that personal care is flexible, consistent and responsive to the changing needs of service users. This is well documented in care plans. There is good evidence of health care screening in care plans. People who use the service are able to choose their own GP and there is evidence on file of the healthcare support available to individuals. It is clear Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 16 that routine appointments are attended in line with NHS entitlements and all initiatives recorded. Recently the unit organised a breast awareness teaching session for care staff and people who use the service. This is to be commended. People who use the service receive additional support through the Learning Disabilities Community Team, where they can access physiotherapists, occupational therapists, speech therapists and other specialist service they may require. Staff provide support to individuals needing to attend outpatient and other appointments. The unit operates a link worker system. There were no people choosing to administer their own medication at the time of the inspection. Since April 2007 the home has been using a Monitored Dosage System (MDS). The supplying pharmacist has visited the home once in December 2007 to advice on storage, records and safe practices. There were no out of date medications held in the flats of people using the service and there is a returns procedure in place. The inspector examined medication records and these were found to be fully completed with no omissions noted. Training records demonstrate that seven staff completed training in medication administration provided by the organisation and facilitated by a pharmacist tutor in 2006. The senior support worker has also completed training in the Safe Handling of Medicines. There are numerous hand-written entries on medication records that are not signed or dated. These must be signed by two staff and dated and is strongly recommended. There is a new medication policy dated January 2007. Haddon (42a) DS0000028414.V357881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. Procedures for managing complaints and adult protection are in place but need some minor revision to ensure people have accurate information to hand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a corporate complaints procedure however the staff were unable to find this during the inspection. The registered manager stated that she would obtain a copy for the unit. There is a pictorial complaints procedure available for people who use the service, in each flat. 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. The unit has received no complaints since the previous inspection. People who use the service or their representatives had made no complaints directly to the Commission. There are adult protection procedures in place. These refer to out of date legislation and refer staff to the “registering authority”. Updating is needed to amend the legislative background, if the policy is to mention this, and to make sure that staff know that they are to report adult protection matters to the Commission. There have been two adult protection referrals made in the past year, according to information supplied before the inspection. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 18 Training records demonstrate that training in Safeguarding Vulnerable Adults is up to date for care staff. The homes policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. Staff are instructed during induction about physical and verbal aggression by a service user. Haddon (42a) DS0000028414.V357881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29 and 30. Quality in this outcome area is good. A clean, comfortable and homely environment has been created for people who use the service, ensuring that they have appropriate surroundings in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service consists of six flats, numbered 34 to 42 Haddon in Great Holm. The six flats are divided into one and four bedroom flats. The staff office is separate to the flats although very close by. From Great Holm, service users have good access to the facilities within Milton Keynes city centre and there are good transport links. Three of the six flats were toured as part of this visit and people who live in the flats were asked permission by staff for entry. Many people who use the service were out at work on the day of the inspection. One person offered to show their room to the inspector. This was Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 20 decorated in a style that demonstrated the individual’s interests and preferences. There were five requirements issued at the previous report regarding improvements to the environment. These were 1) the toilet and bathroom in flat 40 be redecorated following the removal of radiators, 2) the sealed unit window, in the patio door of flat 40, is either repaired or replaced, 3) the Patio area outside flat 40 is made safe, 4) the kitchen and flooring in flat 36 is replaced and 5) the bathroom in flat 36 is replaced. Although the inspector did not view all the flats the registered manager confirmed that all the requirements have been complied with and work completed. Lounges in all flats are homely in appearance and looked bright and comfortable. In one lounge the people who live there have chosen to have a snooker table. The flats are generally clean with no odours. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The home has an infection control policy and the inspector observed this. Training records demonstrate that all staff have attended Infection Control training in the last twelve months. Haddon (42a) DS0000028414.V357881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. The staffing numbers and skill mix is adequate and improvements have been made in staff training to ensure that people who use the service benefit from staff who are who are competent to do their job. Recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a small group of staff providing support and care to people who use the service. Some progress has been made with NVQ training. The registered manager has completed the NVQ level 4 training and Registered Managers Award, the senior support worker has achieved NVQ level 3 training, one care worker is due to complete NVQ level 3 and another level 2 in the near future. One care staff member has registered to undertake NVQ training. Following the previous inspection a requirement was issued for relief staff to be up to date with all mandatory training. The registered manager stated that this is often difficult as some relief staff do not work many hours and attending Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 22 training is difficult for them. This is an area that needs to be appropriately addressed by the organisation to ensure relief staff do not work without the necessary training. It is noted that the organisation has a formal agreement with the Commission for it to hold centrally some specific staff recruitment documentation and maintain a signed checklist within the home. Following the previous inspection a requirement was issued for the unit to maintain evidence of all recruitment checks for staff, as detailed in schedule 2. Four staff recruitment files were viewed at this inspection including those new to the service. The files looked at do contain a checklist of all employment checks. However, under the reference checks there is just a tick and it does not record the dates these were received or who the references were from and there is no copy of any application forms. Two Criminal Records Bureau (CRB) checks were dated 2003 and it is recommended that where these are dated 2003 or 2004 that these are renewed. Copies of certificates from courses attended have been collated for each person working at the service. These demonstrate that all staff are up to date with basic food hygiene training, first aid training and Moving and handling training. The registered manager said that all newly employed care staff now undertakes a five day induction via Milton Keynes Council and this covers mandatory health and safety training. The inspector saw evidence of this for the newest staff members. Haddon (42a) DS0000028414.V357881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. The home has implemented a quality assurance system but this needs to be strengthened and delivered more consistently to ensure the unit is being proactive in identifying issues that may effect the well being of people who use the service. The home has a registered manager ensuring continuity of care, and there are systems in place within the home that are used to ensure that health, safety and welfare of the people who use the service are protected and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. She has attained National Vocational Qualification level 4; her post comes with a job description outlining duties and responsibilities. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 24 The registered manager reports to an external line manager who carries out her supervision monthly and undertakes monitoring visits on behalf of the provider. Examples of further training in the past twelve months include, equality and diversity, medication training, first aid, Infection Control and the Mental Capacity Act. During the inspection there were satisfaction questionnaires that had been sent out to individuals who use the service. These were dated April 2006. At the previous inspection a request was made for a copy of the published results of the survey to be sent to the Commission. This had not been done and leaves the exercise open ended. Should a further exercise be carried out this year, it would be expected that a registered manager collate the findings as part of their professional role and share these with the people who took part and relevant parties. Monthly monitoring reports were looked at for the past five months and they follow a detailed format that shows speaking with staff and people who use the service is a regular feature of the visits, plus good practices such as examining a sample of individuals money and staff training records. There is a forum that is held twice a week and is facilitated by an independent person. This is open to all people who us the MacIntyre services at the Great Holm site. Flat meetings and link worker meetings take place on a regular basis and minutes are kept of these which were observed at the inspection. A care worker in the unit has started a monthly magazine and people who use the service are invited to include photos or stories. This magazine goes out to the people who use the service, their relatives and friends. This is to be commended. It is pleasing to see that parents and relative meetings have recommenced and the next one is due to take place on Saturday 26th 2008. This is an example of good practice. A range of health and safety checks are in place at the service and carried out on a daily, weekly or monthly basis. Two requirements were issued following the previous report for 1) gas servicing appliances to be produced to the Commission and 2) risk assessments for hot water outlets are reviewed and action recorded. It is pleasing to see that these have been complied with. This years gas servicing took place on 09/01/08 and the unit was awaiting the certificates. The fire risk assessment was looked at and is fully completed and is dated 08/06/07. Training records show that not all care staff have received up to date fire training. One care staff has not attended since 2005. A requirement has been issued for improvement in this area. Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 25 The last visit by the fire authority was on the 18/01/08. It was required that two door frames with holes in them are repaired or replaced. A letter sent to the maintenance department for the organisation was seen in regard to this. Haddon (42a) DS0000028414.V357881.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 X 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 3 X 3 X 3 X X 2 x Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Non 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 YA23 Regulation 13(6) Requirement Timescale for action 30/04/08 2 YA42 23(4)(d) The adult protection policy is to be updated to reflect current legislation (if legislation is referred to) and to make explicit to staff that they are to report adult protection matters to the Commission. The registered person is 30/03/08 required to ensure that all care staff receive up to date fire training and this is recorded. 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 YA6 YA20 YA34 Good Practice Recommendations It is recommended that a reduction of unnecessary information contained in care plans is completed which would make the care plans more user friendly. It is strongly recommended that all hand-written entries on medication records are dated and signed by two staff. It is recommended that all Criminal Bureau Checks completed in 2003 and 2004 are renewed to ensure people DS0000028414.V357881.R01.S.doc Version 5.2 Page 28 Haddon (42a) who use the service remain protected by the organisations recruitment practices . Haddon (42a) DS0000028414.V357881.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Haddon (42a) DS0000028414.V357881.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. 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!