Inspection on 30/08/07 for 3 Mallard Close

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 26/04/06

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 Unannounced Inspection 30th August 2007 10:55 Mallard Close (3) DS0000028364.V341874.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 Mallard Close (3) DS0000028364.V341874.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. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 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.V341874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NA Date of last inspection 26th April 2006 Brief Description of the Service: 3 Mallard Close is one of a number of care homes in Wiltshire 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, two storey property in a residential area on the outskirts of Melksham. The accommodation includes four single bedrooms, a lounge with a dining area, a kitchen and a separate utility room with laundry facilities. The lounge has patio doors to a garden at the rear of the property. One of the bedrooms is on the ground floor and is next to a shower and toilet. Upstairs there is a bathroom and a separate toilet. There is an office and sleeping-in room for staff use. People living at the home receive support from the home’s manager and a permanent staff team. Relief staff are also used on occasions. The fee level at the time of this inspection was from £694.89 - £831.03 per week. Information about the service provided is available in the home’s ‘Statement of Purpose’. Copies of inspection reports are available from the OLPA office at Beckford House, Gipsy Lane, Warminster, Wiltshire, BA12 9LR. Inspection reports are also available through the Commission’s website at: www.csci.org.uk Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection included an unannounced visit to the home, which took place on 30th August 2007. The visit started at 10.55 am and lasted until 2.25 pm, when people in the home had planned to go out. The home had two vacancies at the time of the visit. Evidence was obtained during the visit through: • • • • Time spent with the two people who live at the home. A meeting with the staff member who was working at the time. Observation and a tour of the home. An examination of records, including the two people’s personal files. Other information has been taken into account as part of this inspection: • • • • An Annual Quality Assurance Assessment (referred to as the AQAA) that was completed by the manager. Copies of staff rotas and an annual development plan that were received from the manager before the visit. Comments that were received from two people who completed surveys that were sent out by the Commission. Copies of staff training and development records that were received from OLPA after the visit. There was a telephone discussion on 13th September 2007 with Ms Wendy Godsell, the home’s manager. The outcome of the inspection was discussed and Ms Godsell provided some additional information about the running of the home. The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visit. What the service does well: People live in homely surroundings and are part of the local community. Their diverse needs and personal goals are well written down in individual plans. This helps to ensure that staff know what people want to do and how to provide personal support. Staff are aware of the risks involved in some activities and help people to participate safely. There are regular meetings so that people can discuss their day to day support and routines. Their individual plans are then amended, so that they reflect people’s current needs. The meetings help people to make their wishes known and to make choices about the meals, outings and routines in the home. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 6 People receive practical support with following their different interests, such as steam engines and crochet. One person was looking forward to staying in the caravan that OLPA owns in Weymouth. The accommodation is generally well maintained and decorated. People like to spend time in their own rooms, but also enjoy using the lounge. There is a garden, which is easily accessible from the lounge. One person in particular likes to use the garden and to grow plants. People help with domestic tasks in the home within their capabilities. There is no pressure to fit in with a particular routine. Mealtime arrangements are flexible. People receive support so that they have food that they like and which meets their needs. One service user’s relative visits regularly and is made to feel welcome. People are supported by a manager and staff team who know them well and understand their needs. This helps ensure that people’s personal and health care needs are met. The training and guidance that staff members receive helps to ensure that they support people safely and in a consistent way. The home’s manager is well qualified and experienced, so that people benefit from a well run home. What has improved since the last inspection? Records are being kept, including a ‘Person Centred Plan’, which give information about people’s individual needs and preferences across a range of areas. These records now have more information about people’s nutritional needs and food preferences. Assessments have been undertaken in connection with this. This highlights an important area and helps to ensure that people maintain good health and enjoy their meals. The environment is being improved. A problem with the hot water supply from some outlets has been resolved. People have made suggestions about what they would like, such as having some new plants in the garden. One person has been very successful with growing some tomato plants. There is a new bird table in the garden. It is close to the house and can be seen from the dining table. This has encouraged one person to use the dining room table more, which in turn has made the meals more of a social occasion. The home has started using the ‘Safer food - better business’ system. This helps in monitoring standards of food hygiene and cleanliness in the kitchen. The manager has produced an annual development plan for the home. This has identified some improvements that will be of benefit to people in the home. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 8 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.V341874.R01.S.doc Version 5.2 Page 9 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): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including the visit to the home. Further information is needed in order to ensure that service users can be confident about the arrangements being made for additional charges and the payment for services that are not covered by the weekly fee. Standard 2 did not apply at the time of this inspection. No new service users had moved into the home during the last year. EVIDENCE: There is a Statement of Purpose for the home. Ms Godsell reported that this is to be developed by including more information and using photographs and symbols to enhance the document. Each person had a service user’s guide to the home. The guides did not include information about the arrangements in place for charging and payment for additional services. Ms Godsell reported that pictorial guides are to be produced. The most recent admission to the home took place in October 2005. Standard 2 was looked at during the inspection in January 2006 and was met at that time. OLPA has a procedure in place for the admission of new service users. Mallard Close (3) DS0000028364.V341874.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. 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 using available evidence including the visit to the home. People’s personal goals and diverse needs are well reflected in their individual plans. People can make decisions about what they want to do and they receive support to reduce the risk of being harmed. EVIDENCE: During the visit people talked about the things that they liked doing, such as going out to a yoga class, growing plants in the garden and visiting museums. One person said that they had recently enjoyed a trip in a steam train. The other person was particularly keen on crocheting and making things. People had discussed their wants and needs at meetings and these had been recorded in a ‘Person Centred Plan’. The wants and needs were identified under headings that included Communication; Community Presence; Dignity; Education and Occupation; Emotional and Physical Well-being; Leisure; Making Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 11 Choices; Psychological Needs; Relationships; and Spirituality. One of the people using the service user was in their 40s and the other was in their 80s. The plans highlighted people’s different interests and the support that they needed. One person had felt that they needed to take more exercise and had bought an exercise bike during the last year. They kept this in one of the empty bedrooms and used it during the visit. Another person had wants identified in relation to spirituality and said that they needed to use a large print hymnbook. People’s wants and needs had been prioritised and some goals established. These included, for example, trips being arranged to Longleat; Bath, for shopping; and to a garden centre. At one person’s last review meeting it was recorded that all their goals from the previous year had been met. The staff member who was met with said that the individual plans were a good source of information about people’s needs and interests. The staff member said that there were diaries and a communication book, which helped them to keep up to date about people’s current needs and activities. The risks arising from some activities had been assessed and records kept. In July 2007 a risk assessment had been undertaken about the use of a sewing machine and in the previous month the use of the bath for aromatherapy was assessed. People were meeting with their keyworkers about once a month. Records of the meetings were kept on people’s individual files. The meetings were an opportunity to review progress with meeting goals and to talk about people’s general well-being. The care and assessment records contained guidance about some limitations that applied in what people were able to do. For example, decisions had been recorded about how service users would manage their personal money in conjunction with staff. These agreements had taken into account the service users’ vulnerability and their capacity to keep money safe. ‘Tenants’ meetings were being held, when people were given time to talk about the home and what they do. There was a ‘rolling’ agenda, which included meals; days out; and relationships. An agenda book was kept in the lounge. Ms Godsell reported that it was the intention to make this a pictorial version to assist with communication and ideas. In their surveys, both respondents stated that the home always met people’s different needs. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including the visit to the home. Service users are involved in the local community and have activities they enjoy. The involvement of family members is welcomed and supported. Service users can make choices about their daily routines and the meal arrangements. EVIDENCE: The two people living at the home were both present throughout the inspection visit. They were choosing how to spend their time and plans were being made with the staff member about what to do later in the day. One person watched a television programme during the morning and appeared to enjoy a relaxed lifestyle in the home. They had a favourite place to sit in the lounge. They said that they went to a few regular activities outside the home, such as a coffee morning and Gateway club. This person particularly Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 13 liked the occasional social outings that took place. They were looking forward to having a holiday in a caravan in Weymouth that is owned by OLPA. The home has its own vehicle for trips out. The other person had a more varied week, which included going to college and to a specialist day centre in Bath. The staff member spoke about the discussions that had taken place about this person’s participation in activities. These were reflected in their Person Centred Plan. Information about people’s family details and relationships was recorded in their personal files. One person said that they spent time with a family member every two weeks. In their surveys, both respondents stated that the home always helped people to keep in touch with them and that they were kept up to date with important issues. One respondent commented that they enjoyed visiting the home and were able to stay for lunch. One person said that they liked helping to look after the house cat. The person also liked doing things in the garden and was growing tomato plants. There had been a discussion at a tenants meeting about new plants that people would like to have in the garden. Records were kept which showed a range of meals were served, reflecting individual preferences. People could choose to eat in the kitchen or in the dining area of the lounge. There was encouragement for some meals to be eaten together in the dining room to make it more of a social occasion. During the visit, people had lunch together at the dining table but had chosen different things to eat. Records showed that a dietician had given advice about healthy eating. People contributed to the household tasks and this was referred to in the service user guides and other documents. Each person had their own room where they could be private. It was evident during the inspection that people had the freedom of the home and could choose where they wished to spend their time. There was a computer in the lounge. Ms Godsell reported that there were plans to purchase computer games and software programmes that would be of interest to people living in the home. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 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. 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 using available evidence including the visit to the home. People’s health and care needs are being met. People are protected by the way that their medication is managed. EVIDENCE: Care plans were kept in people’s individual files, which provided information about personal support and how this would be provided. Statements had been written about gender and the provision of personal care. Linked to the care plans were forms for the recording of reviews and for identifying any changes that had been made to the plans. Recent changes had involved the support that people receive with budgeting, medication and personal care. Guidelines for support had been produced in areas such as nail cutting, bathing and managing certain behaviours. An occupational therapist had recently been involved in producing new guidance about how people can use the bath safely. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 15 Ms Godsell reported that one improvement since the last inspection had been the implementation of nutritional assessments. People’s personal files now contained records relating to their nutritional needs. These included dietary assessments and individual menu plans. This information helped to highlight an important area. The staff member who was met with was aware of this development and of the need to be aware of one person’s needs in particular and their food intake. People were up and about at the time of the visit and personal support was limited to verbal prompting and support with some domestic tasks. During the morning, the staff member suggested to one person that they might like to have a drink. This was positively responded to and followed up by the person being involved in making it. The staff member confirmed the importance of people being encouraged to participate in such tasks within their capabilities. In their surveys both respondents stated that the home always gave people the care that they expected. They commented that people’s needs were met; that they looked well; and liked to show off any new clothes. Some of people’s health and personal care needs were also highlighted in their Person Centred Plans. One person had wanted a new pair of shoes. This had then involved a special fitting, as the shoes needed to be adapted to meet their individual needs. People’s personal files included forms for the recording of visits to doctors, dentists and chiropodists. A number of visits had taken place in the last few months. Some entries were also recorded in people’s personal diaries. People received support from staff with the safekeeping and administration of their medication. They had signed a form giving their consent for this. There were suitable storage facilities. A medication file was kept in the office, which included a copy of OLPA’s medication procedure. There was other guidance for staff, such as the need to be aware of expiry dates and information about the medication that people were prescribed. OLPA provided ‘in-house’ training in medication, which the staff member who was met with said they had received. It has been recommended at previous inspections that staff also have the opportunity to receive some external training. Ms Godsell reported that the training now included a video and workbooks that had been produced by a training consultancy firm. Records were being maintained for the receipt and disposal of medication. Records of the administration of medication were up to date. It had been recommended at the last inspection that written entries on the medication administration record should be checked and counter-signed by a second member of staff. This had happened on some occasions, but not consistently. Sometimes a GP had signed next to a hand written entry. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 16 Special forms were available for the recording of PRN (as required) medication. On occasions, these had been used for the recording of short courses of medication, such as antibiotics. It was confirmed with Ms Godsell that a more appropriate form should be used. Mallard Close (3) DS0000028364.V341874.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 overall, but there are shortcomings. This judgement has been made using available evidence including the visit to the home. People are listened to and encouraged to express their views. Staff members receive information about abuse and the reporting of allegations. However people may not be protected as well as they should be, because the information is not up to date. EVIDENCE: OLPA had produced a complaints procedure, which was available in the home. The service user guides contained information about how to make a complaint. In their survey, one respondent confirmed that they knew how to make a complaint and was confident that the home would respond appropriately to any concerns raised. The other respondent did not comment on this, but confirmed that they got all the information they needed from the staff members, who were very helpful. Ms Godsell reported that the home was continuing to look at ways of promoting the complaints procedure and people’s understanding of what to do. Recent developments had resulted in compliment and complaint forms being kept in the front hall to help with their accessibility. Stamped addressed envelopes have been added to the service users guides, which people could use if they wished to speak to a CSCI inspector or make a complaint directly to the Commission. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 18 People could also raise any issues or concerns during their keyworker review meetings or at the tenants meetings. It was reported in the AQAA that it was the intention to include a reminder of the complaints procedure at a tenants meeting every quarter, to ensure that people feel confident and are knowledgeable about the complaints process. Ms Godsell reported that there have been no complaints or safeguarding adults investigations involving the home during the last year. The staff member who was met with was aware of the ‘No Secrets’ guidance about abuse and what to do if abuse is suspected. A policies and procedures file in the home included information about the protection of adults in Swindon and Wiltshire. However this had not been updated with the more recent version that is now available. This was brought to Ms Godsell’s attention. OLPA ‘in-house’ training for staff included a course in ‘Abuse Awareness’. The staff training records showed that staff had received this training in November 2005 or June 2006. It was stated in the records that staff received this training once during their employment. It was reported at the last inspection that staff members might 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. Mallard Close (3) DS0000028364.V341874.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to the home. People live in a homely environment. The accommodation is kept clean and tidy. EVIDENCE: 3 Mallard Close is located in a well established residential area. It did not stand out as being a care home and the appearance was in keeping with the neighbouring properties. There were few facilities in the immediate vicinity, although there was a convenience store nearby. People went to one of the nearby towns for most shopping trips. The home appeared well maintained and tidy. Problems with the supply of hot water have been reported on at previous inspections. These have been followed up by OLPA with the housing association that owns the property. The supply of hot water at all outlets was tested during the visit and found to be satisfactory. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 20 People had personalised their own rooms and the communal areas looked homely. New dining furniture had been bought since the last inspection. It was reported in the ‘What we could do better’ section of the AQAA that a new lounge suite could be provided. This was showing some wear. Plans for improvement in the next 12 months included the redecoration of the kitchen and the utility room. Ms Godsell reported that a new lounge suite was also to be bought. It was evident during the visit that people liked to use the lounge and enjoyed the garden, which was easily reached using the patio doors. A new bird table had been set up where it could be well seen from the dining area in the lounge. This had meant that one person was more inclined to use the dining table, which was being encouraged. Ms Godsell 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 there were no unpleasant odours. Staff members were taking the lead in cleaning the home. There were rotas and job lists for particular tasks, such as cleaning in the bathroom and the kitchen. People helped with cleaning their own rooms. During the last year the home has implemented the ‘Safer food - better business’ system for the monitoring of standards in the kitchen. In their survey, one respondent commented that staff did all they could to keep the home clean. Laundry facilities were available in a utility room. This meant that the laundry could be kept separate from the kitchen and dining areas. OLPA had produced guidance for staff about infection control and communicable diseases. Food hygiene and infection control were included in the staff training programme. Mallard Close (3) DS0000028364.V341874.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 overall. This judgement has been made using available evidence including the visit to the home. People’ needs are being met by a settled staff team. Staff members’ knowledge and skills will be further enhanced by developments in the training that is provided. EVIDENCE: No new staff had been appointed since the last inspection. Standard 34 was assessed during the inspection in April 2006 and was met at that time. OLPA had a procedure for ‘Recruitment, Selection and Appointment’. This stated that house managers will be involved in this process wherever possible and practicable. Ms Godsell had said at the last inspection that she met with prospective staff members when they visited the home. She gave feedback about the visit but was not involved in the next stage, which included a formal interview. A recommendation was made at the inspection, as it was found that the manager’s level of involvement in the interviewing process was not consistent with their responsibilities and accountability. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 22 The staff member who was met with said that she had worked in the home over several years and was now employed on a relief basis. This mainly involved covering for permanent staff members when they were on leave. The staff member also had experience of working in other OLPA run homes. They had attended some training courses with OLPA, which included first aid and food hygiene. Four members of the staff team (100 ) have achieved a National Vocational Qualification (NVQ) at Level 2 or above. Ms Godsell has completed training to be a marker for the Learning Disability Qualification (LDQ). The staff training records showed that, following induction, staff members attended mandatory training that was usually provided by the OLPA training officer or by a service co-ordinator. This included training in health and safety; manual handling; first aid; drug administration; abuse awareness; fire safety; food hygiene; and infection control. An external trainer had been used for first aid. Staff members also had the opportunity to attend some other courses, in addition to the mandatory training. These courses were offered to all staff or provided in response to individual requests. The records showed a mixed response to attendance on the non-mandatory courses. A consistent approach to providing training in subjects such as equal opportunities, disability equality and anti-racism was not evident. Two staff members had attended a course titled ‘Person Centred Approach’. One staff member had attended an OLPA training day in ‘Freedom, Rights and Responsibilities’ and another had attended a course about mental health awareness. In the ‘What we could do better section’ section of the AQAA, Ms Godsell has reported that the training requirements could be more thoroughly explored. Mallard Close (3) DS0000028364.V341874.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. This judgement has been made using available evidence including the visit to the home. The manager is well qualified and experienced to run the home. People will benefit from the manager’s approach to development and improvement. Arrangements are in place that help to maintain people’s health and safety. EVIDENCE: Ms Godsell is in her second year as the manager of 3 Mallard Close and has had previous management experience in another care service. Ms Godsell has obtained the registered managers award and achieved NVQ in Care at level 4. The records that were seen during the visit were generally being well maintained and there was an organised approach to the administration. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 24 People were able to pass on their views during meetings that they had in the home. There was a policy on quality assurance, which listed out some systems that are 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. It was reported at the last inspection that there was a lack of quality assurance at an organisational level, although Ms Godsell was developing this within the home. A business plan had been written for the home and it had been agreed that it would be beneficial to develop this format to better reflect the outcomes for service users and the feedback that has been received about the service. The Commission has since received a development plan for the home from Ms Godsell. This set out some objectives for the year ahead and identified some achievements. The plan highlighted the importance of supporting people with their nutritional needs. Evidence of developments in this area was seen during the visit on 30th August 2007. OLPA had carried out a survey of its service users and stakeholders during the last year. This has given some indication of standards within the services that the organisation provides. The results of the survey have been collated although a report of the action to be taken has not yet been produced. OLPA has a policy on health and safety and produced a number of procedures in connection with this. Information about health and safety, including the maintenance and servicing of equipment was received from the home prior to the visit. The portable electrical equipment had last been tested in June 2007. Gas appliances and the heating system were serviced in January 2007. There were written assessments for hazardous substances kept in the home. There were facilities in the home’s utility room for the storage of such materials. Some records were looked at in the home. There was a fire risk assessment, dated 1 June 2007. Assessments had been undertaken in connection with aspects of the environment that could present a risk to people living in the home. These included for example, the use of the garden and items of equipment. A check of the home’s fire log book showed that staff members had last received fire instruction in May 2007 and a drill had been held on 5 August 2007. The fire alarm system was tested on the day before the visit. A maintenance person was working in the home at the time of the visit. The home looked well maintained, with no hazards seen. No accidents had been reported during the last year involving people in the home. Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 25 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 2 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 2 ENVIRONMENT Standard No Score 24 3 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 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 3 x Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5(1)(bc) Requirement The service user’s guide must include the arrangements in place for charging and paying for any services additional to those mentioned in sub-paragraphs (b) and (ba), Regulation 5(1). Timescale for action 31/10/07 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. Refer to Standard YA23 Good Practice Recommendations That the arrangements being made for staff members to receive training and information about safeguarding adults procedures are reviewed. This is to ensure that the guidance that staff members receive is up to date and so that service users will be better protected as a result. That the arrangements being made for the provision of training are reviewed. This is to look at whether changes need to be made in order to ensure that staff members consistently receive training in subjects relating to equality, disability awareness and diversity. DS0000028364.V341874.R01.S.doc Version 5.2 Page 27 2. YA35 Mallard Close (3) 3. YA39 That the policy on quality assurance is amended to include the arrangements made for annual development and for the production of an improvement plan. (Recommendation made at last inspection) Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Mallard Close (3) DS0000028364.V341874.R01.S.doc Version 5.2 Page 29 - 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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