Inspection on 26/04/06 for 3 Mallard Close

This inspection was carried out on 26th April 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Mallard Close 30/08/07

3 Mallard Close 09/01/06

3 Mallard Close 31/08/05

3 Mallard Close 25/02/05

3 Mallard Close 13/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Mallard Close (3) Bowerhill Melksham Wiltshire SN12 6TQ Lead Inspector Malcolm Kippax Key Inspection 26th April 2006 09:20 Mallard Close (3) DS0000028364.V291611.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 Mallard Close (3) DS0000028364.V291611.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. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mallard Close (3) Address Bowerhill Melksham Wiltshire SN12 6TQ 01225 707215 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) Ordinary Life Project Association Wendy Godsell Care Home 4 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (2) of places Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: 3 Mallard Close is one of a number of care homes that are run by the Ordinary Life Project Association (OLPA). The house is owned by West Wiltshire Housing Association. 3 Mallard Close is a detached property in a residential area on the outskirts of Melksham. The house is a domestic style property. Each service user has their own single room. One of the bedrooms is on the ground floor and next to a shower and a toilet. Upstairs there is a bathroom and a separate toilet. There is a lounge / dining room, a kitchen and a separate utility room with laundry facilities. Service users receive support from the manager and a permanent staff team. Relief staff and agency carers are also used on occasions. The fee level as at April 2006 was in the range: £694.89 - £831.03 Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home, which took place on 26 April 2006 between 9.20 am and 4.45 pm. Three service users, a member of staff (who had started during the last year) and the manager were present during the visit. Two service users were met with together in the lounge, and they spoke about the things they do and what it is like to live at the home. A third service user was also met with, although conversation with this person was very limited. The communal areas of the home were looked at and several of the home’s records were examined. A pharmacist inspector from the Commission made a separate visit on 8 May 2006 to look at how medication is dealt with in the home. Staff recruitment records were seen on 16 May 2006 at the OLPA office. Other information and feedback about the home has been received and used as part of this inspection: • • • • The service users’ care managers and close relatives were asked to complete ‘comment cards’, giving feedback about their experience of the home. Two relatives and one care manager have responded. The manager has completed a pre-inspection questionnaire about the running of the home. Reports and notifications have been received by the Commission since the last inspection. Service users have completed survey forms, with support from the manager. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visits to the service and takes into account the views and experiences of people using the service. What the service does well: 3 Mallard Close looked homely and was in keeping with the neighbouring properties. Service users liked the accommodation and their surroundings. They could make choices about their daily routines and had individual lifestyles. Service users were taking part in activities they enjoyed and encouraged to have ideas about new things they would like to do. One service user said ‘the peace and quiet’ when asked what she particularly liked about living at 3 Mallard Close. Another service user said they had meetings when they talked about things such as holidays and how they would like the house and garden to be. Service users also said that they like the home’s cat. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 6 In recent months, the manager and staff team have been very involved with supporting a service user with significant health needs. This has included a high level of support with appointments and good liaison with other professionals. Service users have also received good support with their weight reducing diets. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mallard Close (3) DS0000028364.V291611.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 Mallard Close (3) DS0000028364.V291611.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): 2 This standard did not apply at the time of the inspection. The home had one vacancy. No new service users have moved into the home since the last inspection. EVIDENCE: These standards were not inspected on this occasion. However the Commission has been informed of discussions about contracts that have continued between OLPA and Wiltshire County Council since the last inspection. It is of concern that individual contracts for the service users have not yet been agreed between OLPA and the funding authority. The Commission has raised this with Wiltshire County Council. Since the visit on 26 April 2006, the OLPA Service Co-ordinator has told the inspector and expressed concerns that Wiltshire County Council have not yet produced a contract in respect of a service user who moved into the home during 2005. Mallard Close (3) DS0000028364.V291611.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 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. The service users have ideas about new things they would like to do. Staff members have the information they need to support service users with their goals and their day-to-day needs. Service users have individual lifestyles and can make decisions about what they want to do. EVIDENCE: At the start of the visit, one service user was keen to show the inspector their bedroom, which had recently been redecorated in a new colour. It was later seen that the service user’s wish to have a pink bedroom had been recorded as a goal, using the home’s system of ‘Shared Action Planning’. Other goals, covering areas such as relationships, holidays and trips out, had been recorded in respect of individual service users. The service users’ records included the minutes of meetings that had been held between service users and their key workers. The latest meetings had taken Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 10 place during March 2006. These focussed on the progress that service users were making with their goals and things they wanted to do. The meetings appeared to be a good way of catching up on current affairs. Discussion at recent meetings had included, for example, arranging a boat trip and more personal issues such as support following bereavement. The new staff member met with said that she was familiar with the service users’ individual plans and felt that these were a good source of information about their needs and interests. There was no menu plan used and service users were making decisions about what they would like to eat on a daily basis. Two service users agreed that there were no house rules, but mentioned not being able to help themselves to food from cupboards in the kitchen. This was discussed further with the service users and the manager, who confirmed it was connected with advice about dieting, as two service users were on weight reducing diets. The service users’ records included completed risk assessment forms. Some involved generic, environmental hazards and others concerned individual activities, such as being out in the community and using the kitchen. The assessments included a comment about the gains to the service user, as well as the hazards involved in a particular activity. It is good practice to balance safety and a service user’s rights in this way, as part of a risk assessment process. The service users’ records included information about some limitations that apply in what service users are able to do. These were made in response to the service users’ safety and vulnerability. Agreements had been made about how service users would manage their personal money in conjunction with staff. These had taken into account the service users’ capacity to keep money safe. One service user does not have close family involved and the manager said that she was considering the need for advocacy. Mallard Close (3) DS0000028364.V291611.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visit to this service. Service users participate in the community and have activities that they enjoy. The involvement of family members is welcomed and supported. Service users can make choices about their daily routines and are keen to try some new things. Service users enjoy their meals and benefit from flexibility in the dining arrangements. EVIDENCE: Service users were choosing what to do at the time of the visit. Service users had got up at different times and at about 10.30 am went to a local club for a coffee morning. This, and some other activities, were shown on a ‘Residents Weekly Activities’ form that was displayed in the office. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 12 Some activities the service users did together, such as the coffee mornings and luncheon clubs. Others had been arranged individually. One service user said she enjoyed doing some voluntary work for a local charity. Another service user went to a specialist day centre in Bath and attended Yoga and aromatherapy sessions during the week. This service user was relearning some skills. She said that she was keen on knitting and hoped to be able to do crochet, which was something that she used to do before moving into 3 Mallard Close. The manager said that she was in contact with somebody who could help with this. Enquiries were also being made about activities that the service users might like to join in with at a local community centre. Two service users said that they attend meetings of the Salvation Army each week. The manager said that another service user had no wish to attend a religious service. The home has its own vehicle for trips out. One service user particularly likes to watch television when at home and had had a favourite place in the lounge. This service user appeared to enjoy their retired lifestyle. The other two service users said that they were happy with how busy they were during the week and with the level of planned activities. One service user said that some new clothes had been bought through the internet, with the support of the manager. There was a new computer in the lounge and the manager said that it was planned that service users would have the opportunity to use it. When returning to the home for lunch, service users decided what to eat and where to have it. It was evident during the visit that service users had the freedom of the home and spent their time between the lounge, kitchen and their own private rooms. There was a house cat. Service users were contributing to the household tasks. This involvement was referred to in the service users’ guides and other documents. One service user did their laundry in-between attending activities outside the home. Information about the service users’ personal backgrounds and important relationships was included in their personal records. In their comment cards, the relatives of two service users confirmed that they can visit in private and are welcomed at any time. The manager said that there were good relationships with near neighbours. In the kitchen there was a record of meals that had been served during the week. Details were recorded for each service user, which showed a range of meals reflecting individual preferences. Service users could choose to eat in the kitchen or in the dining room. The manager said that on occasions it suited service users to eat separately, although there was encouragement for Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 13 some meals to be eaten together in the dining room to make it more of a social occasion. Service users said that they like the meals. One service user mentioned the support received with a weight reducing diet and that good progress had been made with this. A dietician had visited in order to give advice about healthy eating. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visit to this service. The service users’ care and health needs are met. One service user in particular has benefited from the support received with some significant health needs. Residents are protected by the home’s procedures for the safe handling of medication. EVIDENCE: Service users were up and about at the time of the visit and personal support was limited to verbal prompting and support with some domestic tasks. Service users said that they felt well supported by staff. The two relatives and the care manager who returned comment cards, were each positive about the overall care being provided to the particular service user they have contact with. Guidance on the service users’ personal care needs was included in their care records and in the relief staff file. A policy on gender and personal care has been developed since the last inspection. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 15 The manager said that each service user was registered with a GP at the same surgery and that regular medication reviews were taking place. The manager has marked the medication records as a reminder of the date on which the reviews are due. The service users’ individual files included forms for the recording of visits to doctors, dentists and chiropodists. A number of visits had taken place in the last two months. Some entries were also recorded in the service users’ personal diaries. One service user spoke about a number of health related appointments and visits that had taken place in recent months. These had required the close involvement of staff, in terms of both practical and emotional support. Details of this were well documented in the service user’s personal file. Medication and records were inspected by the pharmacist inspector and discussions held with the manager. Medication is stored securely and all appropriate records maintained. Staff undergo OLPA training in medication and have available information about all the medicines in use. The opportunity for staff to receive some external training would also be beneficial, as recommended at the last inspection. Written medication administration sheets are used which are signed by the doctor or manager. Photographs are available to aid identification. Changes to medication are recorded. Oxygen is used in the home. There are clear risk assessments and procedures for this and staff have received training. Procedures, agreed with the doctor, are in place for the use of non-prescribed medicines. All residents sign to give consent to receiving medication. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visit to this service. Service users benefit from the management approach to complaints. There is training and information for staff that helps to protect service users. Some further developments would be beneficial. EVIDENCE: Copies of an OLPA produced complaints leaflet were available in the front hall, together with an information leaflet about the OLPA organisation. As reported at the last inspection, the manager has been looking at how service users who wish to make a complaint can do this in a way that meets their individual needs. This has included giving service users stamped addressed envelopes to use if they wish to contact the Commission. The minutes of key worker and tenants meetings showed that concerns within the home are discussed and service users have the opportunity to give their views. The manager said that further consideration is being given to how best to deal with occasional disagreements that arise between two service users. The two service users spoken with mentioned people, both within and outside the home, whom they could speak to if they had a concern about something. One service user was aware of the Commission’s role in relation to complaints and concerns. The manager reported that no complaints have been made about the home during the last year. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 17 In their comment cards, one relative has confirmed that they know about the home’s complaints procedure. Another relative was not aware of it, but stated that if anything is wanted they only have to ask and it is given. The OLPA policies and procedures file includes a brief statement about the protection of vulnerable adults from abuse. This refers staff to the Department of Health ‘No Secrets’ guidance and to the policy and procedure for the protection of vulnerable adults in Swindon and Wiltshire. The member of staff had received a copy of the ‘No Secrets in Swindon & Wiltshire’ booklet. As with other staff members, she had signed the policies and procedures file to confirm that she had read and understood the guidance. OLPA provides ‘in-house’ training for staff in the protection of vulnerable adults. The staff training records showed that all staff, except the most recently appointed person, have attended the OLPA ‘Abuse Awareness’ course. The manager has reported that there have been no adult protection referrals during the last year. The manager has not attended a training course for managers. Staff members may also find that external training in adult protection, for example involving the local vulnerable adults unit, would be useful in addition to the in-house arrangements. Recommendations about this were made at the last inspection. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during the visit to this service. Service users like the surroundings and the accommodation is meeting their needs. The accommodation is clean and appears well maintained, however a difficulty with the supply of hot water is unresolved. EVIDENCE: The home is located in a well established residential area. There are few facilities in the immediate vicinity although service users said that they use a nearby convenience store. One of the nearby towns was used for most shopping trips and for accessing public amenities. Service users were spending time in the home’s lounge, which was homely and comfortably furnished. The accommodation looked well maintained and tidy. It was reported at the last inspection that there was a problem with the supply of hot water to a wash hand basin in the bathroom. The manager said at the time that this was being Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 19 followed up with the housing association that owns the property. The situation appears not to have improved, as only a small trickle of hot water came out when the tap was tried again. A member of staff said that the problem was first thought to be connected with a blockage, but may also be connected with temperature regulators. It was also reported at the last inspection that the bath taps each had a blue spot on them, identifying them both as cold water taps. This has not been corrected. The back garden is accessible from patio doors in the lounge. It looked like a well used area. There was garden furniture, which belonged to one of the service users. A service user has said that the garden has improved during the last year and the manager said that there were plans for it to be landscaped. The manager has reported that an environmental health officer last visited the home in September 2004, with no requirements identified at the time. The areas of the home seen during the inspection looked clean and tidy. Support workers take the lead in the cleaning of the home and there are rotas and job lists for particular tasks such as in the bathroom and the kitchen. Service users do some cleaning of their own rooms. The utility room with laundry facilities was being sorted out at the time of the visit. OLPA provides training for staff in health & safety (including infection control) and in food hygiene. The staff member met with had read the OLPA policy on infection control. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 20 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 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. New staff members get to know OLPA’s procedures, but do not receive the recommended induction for working with people in a learning disability service. There is a well established programme of in-house training. Further developments are taking place, which will be of benefit to service users. Service users are protected by the organisation’s recruitment practices. EVIDENCE: The staff member met with had started employment within the last six months and said that she did not have previous experience of a learning disability service. Her introduction to the work had included an Induction day at the OLPA office, completion of OLPA Induction and Foundation checklist and spending the first two weeks of employment ‘shadowing’ other staff members. The manager said that L.D.A.F. accredited training is not available to new staff and OLPA senior managers have confirmed that it is not the intention to provide this. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 21 The staff training records showed that, following induction, staff members attend mandatory training that is provided by the OLPA training officer or by a service co-ordinator. An external trainer is used for first aid. During the last year some staff members have had the opportunity to attend other external training in areas such as Death, Dying and Bereavement. In April 2006, one member of staff attended an OLPA training day in ‘Freedom, Rights and Responsibilities’, as part of an in-house programme which includes some new subject areas. The manager reported that two of the home’s four permanent support workers have achieved NVQ at level 2. Recruitment was discussed with the OLPA personnel officer and service coordinators at the OLPA office. The main employment records are held centrally, with copies of documentation also kept in the home. It was agreed that future arrangements could include inspection of the records at the office and the need to keep records in the home would be removed. However a recruitment checklist would need to be available for inspection in the home. The employment records for a number of OLPA support staff were looked at. Each staff member had an individual file. There was some inconsistency in the files’ contents and in the completion of an employee information form, which is used as a checklist during recruitment. It is recommended that this form is updated, as a number of new recruitment checks, for example POVA / C.R.B., have been introduced since the form was produced. The files showed evidence of appropriate recruitment practice, including copies of references, application forms and interview records. Documentation relating to C.R.B. disclosures and POVA checks was seen. An administrative error had resulted in one staff member starting at 3 Mallard Close before their C.R.B. disclosure had been returned. This was later resolved and it appeared to be an isolated occurrence. The manager meets with prospective staff members when they visit the home and gives feedback about the visit. The manager said that she was not involved in the next stage, which involves a formal interview. It was stated in the OLPA procedure on ‘Recruitment, Selection and Appointment’ that house managers will be involved in this process wherever possible and practicable. The manager’s level of involvement in the interviewing process was not consistent with their responsibilities and accountability. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visit to this service. The manager has relevant qualifications and experience, which are benefiting service users. There is a lack of quality assurance at an organisational level although the manager is developing this within the home. There are systems in place that help to ensure that service users are not at risk. EVIDENCE: Wendy Godsell has been registered as the home’s manager during the last year. Wendy Godsell has obtained the registered managers award and achieved NVQ in Care at level 4. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 23 The manager has been able to draw on her previous experience in another service. This has resulted in some changes in the home. Service users commented on decoration that had taken place and things that were being done to make the home nice. Administration and filing in the home looked more organised. Service users were able to pass on their views during meetings within the home. There was a policy on quality assurance, which listed out some devices in place for obtaining feedback from interested parties, although the policy did not refer to the production of an annual development or improvement type plan. Quality assurance was discussed at the last inspection and the manager has since written a business plan for the home. The manager said that she was not aware of any policy guidance about the production of such a plan, but she had used a format that she had experience of when working in another service. It was agreed that it would be beneficial to develop the business plan format in a way that better reflects the outcomes for service users and the feedback that has been received about the service. Information about maintenance and equipment servicing was received from the manager in a pre-inspection questionnaire. The smoke alarms were tested by staff during the inspection. There was a risk assessment file, which contained a range of assessment records concerning environmental hazards and others that related to individual service users. The most recent assessments undertaken in 2006 concerned the risk of Legionella and the use of an oxygen cylinder. The home’s fire risk assessment was last reviewed in February 2006. The minutes showed that health & safety is discussed at staff meetings, as a standing item. At a recent meeting, there had been discussion about one service user who was observed to be unsteady when coming down the stairs with their washing. This had been well followed up after the meeting, with the completion of a risk assessment and an amendment to the service user’s care plan. Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 24 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 N/A 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 2 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 2 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 3 x Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 19(1) Requirement The registered person must take action to ensure that hot water is readily available at all outlets. Timescale for action 30/06/06 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 YA7 YA20 Good Practice Recommendations That the need for one or more service users to receive an advocacy service is reviewed and action taken accordingly. That, in addition to the ‘in-house’ training, staff members also receive training in medication from a specialist outside the home. Written entries on the medication administration record signed by staff, should be checked and counter-signed by a second member of staff. That the manager has the opportunity to attended an external course in the protection of vulnerable adults procedure. 3 YA20 4 YA23 Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 26 5 6 7 8 YA34 YA35 YA37 YA39 That the employment checklist is updated to include all aspects of the recruitment process. That L.D.A.F. accredited training is provided for staff who are new to working in a learning disability service. That the registered manager is involved in the formal interviews for new members of staff. That the policy on quality assurance is amended to include the arrangements made for annual development and for the production of an improvement plan. That an improvement / annual development type plan is produced for the home, which reflects the outcomes for service users and the feedback that has been received about the service. 9 YA39 Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Mallard Close (3) DS0000028364.V291611.R01.S.doc Version 5.1 Page 28 - 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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