Inspection on 31/08/05 for 3 Mallard Close

This inspection was carried out on 31st August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

3 Mallard Close 30/08/07

3 Mallard Close 26/04/06

3 Mallard Close 09/01/06

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) 3 Mallard Close Bowerhill Melksham Wiltshire SN12 6TQ Lead Inspector Malcolm Kippax Unannounced 31 August 2005 st 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 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 Stationary 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) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mallard Close (3) Address Bowerhil Melksham Wiltshire SN12 6TQl 01225 707215 01985 847789 olpa@olpa.fsnet.co.uk Ordinary Life Project Association Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 4 Category(ies) of LD Learning Disability (2) registration, with number LD (E) Learning Dis - over 65 (2) of places Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 2 service users with a learning disability 2. No more than 2 service users over the age of 65 years with a learning disability Date of last inspection 25th February 2005 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. The house is owned by West Wiltshire Housing Association. The home is a detached property situated in a residential area on the outskirts of Melksham. It is domestic in style and fits in with the neighbouring properties. There are some shops and amenities nearby. Each service user has their own room. One of the bedrooms is on the ground floor next to a shower and toilet. Upstairs there is a bathroom and a separate toilet. There is a lounge with a dining area, although meals are generally taken in the kitchen. Service users receive support from a manager and staff team. Agency and relief staff are also used. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 9.30am and took place over five hours. There were two service users living in the home at the time. Both service users were spoken with although conversation with one person was very limited. Their rooms were seen and time was spent with service users in the lounge. A relative visited during the morning and spoke of her experience of the home. An agency carer, working by himself, was providing support for service users during the inspection. A selection of the home’s records was examined. What the service does well: What has improved since the last inspection? What they could do better: There was a high use of agency staff at the time of the inspection. The aim should be to have a permanent staff team that can provide support for service users without the regular use of agency or relief staff. There are a number of activities that the service users enjoy and would like to do. However information for staff about the service users’ personal goals was not up to date and support with achieving the goals looked inconsistent and needs to be better planned. The OLPA system of ‘Shared Action Planning’ is not being properly implemented. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 6 Requirements concerning the carrying out of risk assessments were identified at the last inspection. It is a matter of concern that OLPA had not met these requirements by the required date. 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) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 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 standard(s) These standards were not assessed on this occasion. A requirement was made at the last inspection that copies of the local authority’s terms and conditions are obtained in respect of all service users. The availability of this documentation was not confirmed during this inspection. EVIDENCE: Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 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 standard(s) 6 Staff members have the information they need about the service users’ day to day care. A lack of up to date information about personal goals and the service users’ progress with achieving these is likely to affect the quality of life that they experience. EVIDENCE: The service users’ records included personal care plans and guidance on daily routines. One care plan was dated May 2005. The other was originally dated 2003, but this was crossed out to show 2004. The agency carer spoken with confirmed his knowledge of the service users’ day to day care needs. This had been gained from a relief staff file, which the carer felt provided sufficient guidance during his work period. He said that more comprehensive information was available in the service users’ personal files, if needed. Service users spoke about their interests and what they like to do. The two service users’ personal files included documentation relating to the system of ‘Shared Action Planning’, which is used to record personal goals and progress with meeting these. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 10 One of the service user’s Action plans was undated. The contents included one goal that had been written in 2002. Several sections on the goal sheet had not been completed to show whether this had been achieved. The other goal sheet was dated November 2003 and showed that the goal was achieved a few months later. The other service user had a more recent Action plan although the goals sheets were not being consistently completed. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 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 standard(s) 12, 15 and 17 Service users enjoy the activities that are arranged by staff but one service user’s level of participation in activities is not meeting her needs. The involvement of family members is welcomed and supported. Service users generally enjoy their meals and staff members are aware of the service users’ preferences. EVIDENCE: Both service users visit drop-in and luncheon clubs during the week. These occasions are shown on a ‘Residents Weekly Activities’ form that is displayed in the office. For most of the week the form showed no planned activities and service users said that they spend a lot of time in the home. One service user in particular is keen on watching TV and was in the lounge throughout the inspection. One service user said that she would like to have more occupation and felt that there was not enough to do. She was looking forward to a trip to Weston at the weekend. This service user went out with a close relative during the Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 12 inspection and visited a possible placement for voluntary work. The relative spoke positively about her experience of the home. The support that service users receive with their activities will be looked at during the next inspection of the home. A service user spoken with had regular contact with family members. Information about the service users’ personal backgrounds and contacts was included in their personal records. In the kitchen there was a record of meals that had been served during the week. The agency carer said that there was no menu plan to follow and he produced a lunch meal from what was available. Previous records of meals showed that the service users often had different meals, which reflected their individual preferences and needs. One service user said that a dietician had visited in order to give advice about healthy eating and weight loss. Some information about this was available in the kitchen. Bowls of fruit were out on the kitchen table. Service users said that they like the meals. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 The service users’ care and health needs are met although there is a lack of clarity concerning a policy for the provision of personal care in the home. EVIDENCE: Service users were up and about during the inspection and personal support was limited to verbal prompting with some domestic tasks. The agency carer encouraged service users to help with the lunch meal and to clear up afterwards. Guidance on the service users’ personal care needs was included in their care records and in the relief staff file. The agency carer confirmed his knowledge of the support that service users need with their care. The carer said that one service user had been supported with having a shower earlier in the day. The female service user had previously been asked if she was happy to have a male carer assisting her. The agency carer said that this had been discussed with the (female) agency carer who had been working earlier in the day and it was agreed that she would stay on to assist the service user. The agency carer was not aware of any policy about gender and the provision of personal care. Service users said that they were well. Their individual files included forms for the recording of visits to doctors, dentists and chiropodists. A number of visits Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 14 had taken place in the last two months. Some entries were also recorded in the service users’ personal diaries. Although the record of appointments looked up to date, a report of the outcome, for example in connection with blood tests, could not be located. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not looked at on this occasion. EVIDENCE: Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 26 The accommodation is meeting the service users’ needs. The service users enjoy a homely and domestic environment. Bedrooms are well personalised, although the type of floor coverings in two bedrooms look out of place. EVIDENCE: Service users were spending time in the home’s lounge, which looks homely and comfortably furnished. Service users said that the layout in the lounge had recently changed, which they thought was better. There are doors from the lounge to the back garden, which a service user said had improved in recent months. A gardener is involved and the service user herself was growing some tomatoes. She had previously bought some garden furniture for everyone to use. Service users said that they liked the accommodation and their own rooms, which they were happy to be looked at. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 17 Bedrooms had different décor and reflected the service users’ interests and preferences. In one bedroom, and in a vacant room, there was a type of floor covering that is more often found in a laundry or a kitchen, rather than in a bedroom. A service user said that she had not chosen this and it was in place when she moved in. Some rugs had been provided which matched the room’s colour scheme. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Service users appreciate the support that they receive. There is a high use of agency staff and lone working, which has not be assessed as required. Some further written guidance and communication with agency carers is needed. EVIDENCE: The written staff roster showed that there was lone working on most weekdays. There was a high use of agency staff at the time of the inspection, with four different agency carers having worked in the home during the last three days. A requirement was identified at the last inspection concerning the need for a risk assessment to be undertaken in respect of lone working by staff and the use of agency staff. This assessment had not been undertaken by the required date of 31 May 2005. An immediate requirement notice was issued confirming completion of this assessment by 9 September 2005. Service users said that they got on well with both the permanent staff members and the agency carers. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 19 The agency carers had signed a form at the front of the agency file to confirm that they had read the contents. Some carers had done this on their first visit only and others had signed on each occasion they worked in the home. The agency carer said that he had checked the home’s diary/communication book when starting his shift. This had one note for the day, to advise that one of the service user’s relatives would be visiting during the morning. The ‘Residents Weekly Activities’ form showed that another service user would normally have gone out for lunch on that day, although there was no information about how this was arranged and whether it was supposed to be happening on this day. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 There has been a lack of attention to health & safety requirements, which can put service users at risk. EVIDENCE: A requirement was identified at the last inspection concerning the need for a fire risk assessment. This assessment had not been undertaken by the required date of 30 April 2005. An immediate requirement notice was issued confirming completion of this assessment by 9 September 2005. The fire log book was looked at. There was no record of staff members having received instruction in fire precautions after 24 August 2004. This was also the subject of an immediate requirement notice. Information about fire precautions for agency carers was included in the relief file and in the fire log book. A form in the fire log book for agency staff to sign Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 21 was blank. The guidance for agency carers needs to be reviewed to ensure that it is accurate and up to date. Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x x Standard No 11 12 13 14 15 16 17 x 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mallard Close (3) Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 23 YES Are there any outstanding requirements from the last inspection? 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 5 Regulation 5 Requirement That the Commission is informed of the action taken to ensure that copies of the local authority’s contacts/terms and conditions statements are available in respect of all service users. A Lone Working Risk Assessment, including the use of agency staff, must be completed (This requirement is outstanding from the last inspection) A fire risk assessment must be undertaken (This requirement is outstanding from the last inspection That staff members receive instruction in fire precautions That the guidance on fire precuations for agency staff is reviewed to ensure that it is accurate and up to date Timescale for action BY 21/10/05 2. 33 18 09/09/05 3. 42 13 09/09/05 4. 5. 42 42 23 23 09/09/05 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 24 Mallard Close (3) 1. Standard 18 2. 3. 4. 5. 19 26 33 That a statement on personal care is produced to include the organisations policy on gender and personal care and to provide details of any limitations and restrictions that may apply in the provision of personal care That the outcome of visits to health care professionals is more clearly reported within the service users care records That service users are offered the option of having a carpet in their bedroom when moving into the home That more comprehensive information is provided in the home for agency staff about the days activities Mallard Close (3) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 25 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire 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) D51_D01_MALLARDCLOSE(3)_V245342_310805_Stage4.doc Version 1.40 Page 26 - 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!