Inspection on 09/01/06 for 3 Mallard Close

This inspection was carried out on 9th January 2006.

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 4 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 26/04/06

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 9th January 2006 09:20 Mallard Close (3) DS0000028364.V277283.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.V277283.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.V277283.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.V277283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 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 (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. It is domestic in style and is in keeping with the neighbouring properties. Each service user has their own 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 with a dining area, a kitchen and a separate utility room with laundry facilities. Service users receive support from a manager and permanent staff team. Agency and relief staff are also used. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 9.20 am and lasted for four hours. Two service users were met with, as well as two support workers and the home’s manager. The communal areas of the home were seen and several of the home’s records were looked at. Wendy Godsell has been registered as manager since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Staff members have not yet achieved the level of qualification that is expected. There is no accredited programme of induction for staff who are new to working in a learning disability service. There is a lack of evidence in the home to confirm that service users are adequately protected by the organisation’s recruitment practices. The manager is working on a business plan for the home although there is a lack of quality assurance and action plans for improvement. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 6 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.V277283.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.V277283.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 and 5 A new service user is being well supported with settling into the home. Good information is available about the new service user’s needs, although there is a lack of information in other areas. EVIDENCE: A new service user has moved into the home since the last inspection. The service user said that the move had gone well and that she liked living at the home. A personal file has been set up for the new service user. This included a copy of a comprehensive assessment of needs that OLPA had received, which came with recommendations for the type of service and support that would be required. The home had also received some other specialist pre-admission assessments. There was no evidence of a contract / terms and conditions statement in respect of the new service user. The manager said that she had not seen this and would be following it up. Other documentation had been completed following admission. A consent form for the administration of medication by staff had not yet been agreed. The manager said that the settling in period for the new service user had gone well and that the home had received appropriate information about their Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 9 individual needs. Some pre-admission visits had been made to the home, when service users and staff were met with. The Commission has been informed of discussions about contracts that are continuing between OLPA and Wiltshire County Council. 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 also raised this with Wiltshire County Council. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Service users have individual lifestyles and can make decisions about what they want to do. (Standard 6 was inspected and almost met at the last inspection). EVIDENCE: The manager said that the system of ‘Shared Action Planning’ is the main way in which service users can make decisions about their lives. Examples of the service users’ shared action plans, including their personal goals, had been looked at during the previous inspection. The manager said that key worker reviews were an important part of supporting service users with their goals and these were now more consistently carried out. House meetings have not been held recently although the manager said that it was they were to be reintroduced following admission of the new service user. Service users were choosing how to spend their time on the day of the inspection. One service user went to a local club and another was visiting a new centre. The oldest service user was having a more leisurely home-based day. He said that he liked what he did and he appeared to enjoy a retired lifestyle. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 11 There is no menu plan and service users make decisions about what they would like to eat on a daily basis. The service users’ files contained risk assessment forms that have been completed on an individual basis. Some involved generic hazards and others concerned more personal activities. The latter included going to the local shop, withdrawing money and making a hot drink. There is a section of the assessment form for the service user to sign, although in the examples seen this had not happened. The assessments include 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 care and assessment records contained guidance about some limitations that apply in what the service users are 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. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 16 Service users participate in community activities and can make choices about their daily routines. (Standards 12, 15 and 17 were inspected and met at the last inspection). EVIDENCE: The home is located in a well established residential area. The manager said that there were good relationships with near neighbours. There is a convenience store within walking distance. One of the service users collects a paper from the shop each day with the support of a staff member. One service user enjoys doing some voluntary work each week in a local warehouse. There are limited facilities locally and one of the nearby towns is used for most shopping trips and for accessing public amenities. There are also more opportunities for service users outside the immediate area. The home has its own vehicle for trips out. On the day of the inspection, the new service user was visiting a specialist centre in Bath that would best meet her needs. This was with a view to regular attendance each week. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 13 Each service user attends a Salvation Army social and luncheon club at least once a week. Each service user has their room where they can be private. It was evident during the inspection that service users have the freedom of the home and can choose where they wish to spend their time. The service user who was present throughout the inspection liked to have company and had a favourite place in the lounge. He decided when it was time for lunch and prepared his own in the kitchen. The manager joined him for lunch at a table in the kitchen. There is a house cat which one service user is particularly fond of. Service users make some contribution to the household tasks and this is referred to in their service users’ guides and other documents. Mallard Close (3) DS0000028364.V277283.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): 20 Service users are receiving the support that they need with their medication. (Standards 18 and 19 were inspected at the last inspection. Standard 18 was almost met and standard 19 was met). EVIDENCE: Arrangements for the security and safekeeping of drugs were satisfactory. Records for the administration of medication were up to date. Stock records and records of disposal are being maintained. There was a medication file in the office that included a copy of the OLPA procedure for the administration of medication. There was other guidance for staff, such as the need to be aware of expiry dates and information about the medication that service users are prescribed. None of the service users manage their own medication. The new service user had not a consent form in connection with this. The manager said that all staff support service users with medication after receiving instruction in drug administration as part of OLPA’s programme of training. There is no outside specialist input and no external courses have been attended. This is recommended in addition to the in-house’ arrangements. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 15 The manager said that each service user was registered with GPs at the same surgery and that regular medication reviews were taking place. The manager marks the medication records as a reminder of the date on which the reviews are due. It was recommended at the last inspection that a statement on personal care is produced to include the organisations policy on gender and the provision of personal care. The manager said that this had been written although it was available at the time of the inspection. A copy of the statement is to be sent to the Commission. Mallard Close (3) DS0000028364.V277283.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 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: An OLPA produced complaints leaflet is available to service users. This is for general use and 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. A development of this system was discussed during the inspection. No complaints have been received by the home during the last year. 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 manager understood this to mean the ‘No Secrets in Swindon & Wiltshire’ booklet. Copies of this have been given to staff members. All except the most recent staff member had signed the form in the policies and procedures file. OLPA provides ‘in-house’ training for staff in the protection of vulnerable adults. The records showed that all staff, except the most recently appointed have attended the course. The manager said that the new member of staff’s name was down to attend when the next course is held. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 17 The manager said that no referrals have been made under the vulnerable adults procedure 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 a local vulnerable adults unit, would be useful in addition to the in-house arrangements. Mallard Close (3) DS0000028364.V277283.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): 30 Service users live in clean and domestic surroundings. (Standards 24 and 26 were inspected and met at the last inspection). EVIDENCE: The manager said that an environmental health officer had last visited the home in September 2004. The report stated that the premises were ‘generally clean and tidy’. The areas of the home seen during the inspection were also 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 in their own rooms. There is a utility room with laundry facilities, which means that washing can take place away from the food preparation and serving areas. OLPA provides training for staff in health & safety (including infection control) and in food hygiene. Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 19 At the time of the inspection, there was a problem with the supply of hot water to the wash hand basin the bathroom. This appears to be an isolated problem as other outlets were not affected. Service users have wash hand basins in their own rooms. The manager said that the housing association who own the property were aware of the problem although it was agreed with the manager that they need to be contacted again to ensure it receives attention. It was seen in the bathroom that both bath taps were had a blue spot on them, identifying them as cold water taps. This should be corrected. Mallard Close (3) DS0000028364.V277283.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 Changes in the staffing arrangements have been beneficial for service users. Training is provided through in-house activities but the benefits for service users are reduced by the lack of an accredited programme of induction for new staff. Staff members have not yet achieved the level of qualification that is expected. There is a lack of evidence in the home to confirm that service users are adequately protected by the organisation’s recruitment practices. (Standard 33 was inspected and almost met at the last inspection). EVIDENCE: A new staff member has started in the home since the last inspection. The manager said that this had been a successful appointment and there had since been an increase in ‘double cover’ during the day. The new staff member did not have previous experience of learning disability services. There is an OLPA induction programme, although Learning Disability Award Framework (LDAF) accredited training is not being provided. OLPA are therefore not achieving the standard for staff training and development. OLPA have previously been recommended to arrange LDAF accredited training, which Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 21 will provide staff with the underpinning knowledge for progress towards achieving NVQ. The staff training records showed that following induction, staff members attend a range of relevant courses as part of OLPA’s in-house training programme. None of the staff team have achieved NVQ at level 2. An employment file had been set up for the new member of staff. This contained application and interviewing forms, references and other recruitment documentation. There was no record of a POVA / C.R.B. check having been undertaken. The manager understood that a C.R.B. disclosure had been obtained after the member of staff had started, but did not know at what stage a POVA check had been made. Mallard Close (3) DS0000028364.V277283.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 and 39 The home is benefiting from a new manager who is well qualified and has relevant experience. Opportunities for management development appear to be limited. There is a lack of quality assurance and action plans for improvement. (Standard 42 was inspected and not met at the last inspection). EVIDENCE: Wendy Godsell has been registered as the home’s manager since the last inspection. Wendy Godsell has obtained the registered managers award and has achieved NVQ in Care at level 4. It was evident from conversation during the inspection that the management approach is appropriately focused on the needs of the service users. The manager has been able to draw on her previous experience in another home. Wendy Godsell said that she was not aware of a specific training programme for managers, other than participation in the events that OLPA arranges for Mallard Close (3) DS0000028364.V277283.R01.S.doc Version 5.1 Page 23 members of the staff team. She had not been asked to participate at the formal interview stage for the recruitment of a new staff member. The manager said that service users were able to pass on their views during keyworker reviews and through shared action planning. There was no evidence in the home of an organisational approach to quality assurance that is in line with National Minimum Standards. The manager said that she was working on her own business plan for the home for the year beginning April 2006. The general content of this was discussed. In the absence of another improvement or annual development type plan at this time, the manager said that she will develop the business plan in a way which reflects the aims and outcomes for service users. Shortcomings in respect of Standard 42 were addressed following the last inspection. Mallard Close (3) DS0000028364.V277283.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 3 3 X 4 X 5 1 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 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 2 X X X X Mallard Close (3) DS0000028364.V277283.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 YA5 Regulation 5 Requirement A copy of the new service user’s contract / terms and conditions statement must be kept in the home. A record of the issuing of a POVA / C.R.B. disclosure for staff must be kept in the home. The Commission must be informed of the date on which the outcome of a POVA and a C.R.B. disclosure was received in respect of the new member of staff. An improvement / annual development type report must be produced in accordance with Regulation 24 of the Care Homes Regulations. Timescale for action 28/02/06 2. 3. YA34 YA34 19(1) 19(1) 28/02/06 28/02/06 4. YA39 24 31/03/06 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. Refer to Standard YA18 Good Practice Recommendations That a statement on personal care is produced to include DS0000028364.V277283.R01.S.doc Version 5.1 Page 26 Mallard Close (3) 2. 3. 4. 5 YA23 YA35 YA37 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, in addition to the ‘in-house’ training, staff members also receive training in medication from a specialist outside the home. That the manager has the opportunity to attended an external course in the protection of vulnerable adults procedure. 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. Mallard Close (3) DS0000028364.V277283.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.V277283.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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