Inspection on 30/09/05 for 3 Moultrie Road

This inspection was carried out on 30th September 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 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 Moultrie Road 22/11/07

3 Moultrie Road 14/11/06

3 Moultrie Road 27/01/06

3 Moultrie Road 10/11/04

3 Moultrie Road 19/05/04

3 Moultrie Road 22/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 3 Moultrie Road 3 Moultrie Road Rugby Warwickshire CV21 3BD Lead Inspector Warren Clarke Unannounced Inspection 30th September 2005 09:30 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 3 Moultrie Road Address 3 Moultrie Road Rugby Warwickshire CV21 3BD 01788 547585 01788 547585 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) Rethink Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2004 Brief Description of the Service: 3 Moultrie Road is a large, three-storey, Victorian town house, close to the centre of Rugby. It is owned and managed by Rethink (formerly The National Schizophrenia Fellowship). The Home is domestic in nature and is indistinguishable as a care home from the neighbouring properties. The rooms are large and airy and generally well maintained. The home caters for six service users with enduring mental health problems, providing 24-hour support and encouragement to enable service users to regain their independent living skills. The Home is within walking distance of the town centre; there are accessible gardens to the rear of the property. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted during an afternoon and into the evening and therefore the inspector was able to observe the changeover of a shift and how service users are looked after during this period. In conducting the inspection account has been taken of the findings of the last inspection visit and the Manager’s account of progress made in correcting the deficits, which were identified then. In the course of the visit, service users and staff were interviewed, the premises were assessed and relevant records were examined. The inspector was also able to devote some time directly observing the interactions between service users and the staff on duty. Where reference is made to the standards (e.g., as in standard 2.1) this relates to the National Minimum Standards for Younger Adults and where the regulations are referred to this means The Care Homes Regulations 2001. In the Scores section of this report N/A has been inserted against standard 37 because a registered manager is not currently in post. What the service does well: What has improved since the last inspection? At the last inspection 12 areas were identified where improvements were necessary. In summary, these related to ensuring that some records and documents such as the Statement of Purpose and the Service User Guide be revised so that they conform to the standards and the regulations. There were also some health and safety issues relating to safety procedures for service users who administer their own medication, broken tiles in one of the shower cubicles and the storage of potentially hazardous substances. All the other matters were about failure to conform to certain administrative requirements such as staff records and introduction of a quality monitoring system. Encouragingly, most of those matters have been addressed successfully. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 6 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. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 The system currently in place is capable of ensuring that the needs and aspirations of any new service users would be assessed on a multidisciplinary basis led by mental health specialists. Those currently resident at the Home have all been so for considerable periods, but it was difficult to assess how their current needs and aspirations relate to their original comprehensive assessment or any clear assessment of their current circumstances. EVIDENCE: This standard is bounded in provisions that the Home makes for the assessment of prospective service users’ needs and aspirations. Since no-one has been admitted to the Home for some time, the extent to which the initial and ongoing assessment informs plans to meet current service users needs and aspirations was evaluated. What was found was that there was in some cases no evidence of an initial comprehensive assessment though there were reports on specific issues by mental health specialists. There was also evidence of ongoing assessment conducted by staff of the Home, but this was limited to identification of needs in relation to the individual service user’s activities in daily living and other aspects of life and self-care skills. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 9 Lacking is a clear strategy, which informs on what is being worked towards as outcomes. For example, is the individual’s residency at the Home permanent; can he or she be enabled to progress to more independent or semiindependent living in the community and what objectives need to be set for achieving this? This observation should not detract from the actual good quality routine care that service users are receiving, but if a state of drift is to be avoided then more systematic planning is indicated. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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): 6, 7 and 9 Although, as highlighted in the commentary for standard 2, more needs to be done to introduce a more systematic approach to formulating service users’ individual plans, the ethos and practices in the Home are centred on service users participating in decisions about their lives and being supported in responsible risk taking to facilitate recovery. EVIDENCE: Examination of service users’ records revealed that they all have a document: the Recovery Plan, which is the equivalent of the individual plan referred to in Standard 6. Those plans, however, are not clearly derived from an assessment that takes account of all the areas of needs cited in standard 2.3 and are particularly lacking in terms of details of any rehabilitation programme. Service users were aware of the goals in their individual plan and there was evidence that they are reviewed, with the individual service user’s involvement, at reasonable intervals. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 11 The plans did, in all cases, include an assessment of risk, but in order to make them more effective, they need to be informed by up-to-date assessment of the areas specified in standard 2.3, they need to reflect overall aim of the placement (what it ultimately is intended to achieve) and the service users’ own aspirations beyond day-to-day self-care type activities, and how they are being, or are to be, supported to achieve them. It is fair to say, that the Home does have, in the Recovery Plan idea, a commendable care management system, but it needs to be applied with greater clarity, systematically and focus on the immediate as well as longer term goals. Service users in their conversations with the inspector confirmed that they are fully involved in decisions about them and largely left to live their own lives as they choose. That is, with such support, as they need, they do their own cooking so decide what they eat; purchase and look after their own clothes, manage their own money and journey out of the Home at any reasonable time as they wish. In addition to service users’ personal risk assessments, measures such as regulating the hot water temperature and fire precautions have been taken to ensure that service users can live full lives in an environment where predicable risks are controlled. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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): 12, 13, 15, 16 and 17 The Home lies in the heart of the local community and is run on a basis, which enables service users to pursue social and cultural activities within the community. Nothing in the way that the Home is operated and the practices it has adopted places any curtailment upon service users, independence, choice, rights and responsibilities. Service users appeared active and in reasonable physical health suggesting that their diet might be a contributory factor. EVIDENCE: The Home being within a short walking distance of the town centre enables service users easy access to local social and cultural activities. Service users told the inspector that they have access to a Resource Centre where they are able to pursue creative activities and socialise. Staff also reported that some service users enrol in courses at the local FE College. One service user explained the ways she is involved in the local community as attending the local Resource Centre, using the local shops, and generally associating with local people. For example, she knows a lady across the road and is crocheting a blanket for her. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 13 Staff confirmed that other service users were involved in the community to a similar extent, though they all have different interests and social groups. The Home’s Statement of Purpose, and its portfolio of policies and procedures set out the provisions made to enable service users to maintain contact with relatives and friends. For example, a pay telephone is available for service users to make and receive calls and visiting times are flexible. One service user cited instances in which staff members have facilitated contact with the individual’s family member who lives some distance away from the Home. The service users whose views were sought on this aspect of their care indicated that they had no concerns. Recognition of service users’ adult status is spelt out in the Home’s Statement of Purpose, which was recently updated, in terms of providing care and support in ways that promote independence, privacy, choice and rights, etc. These tenets, as assessed by the inspector, are reflected both in care practices and provisions. That is to say, each service user has his or her own bedroom, which is regarded as the individual’s own private space. They are provided with a key to their rooms and staff only enter with their permission unless in an emergency. They also have their own front door key so that they can come and go without undue restrictions and, providing for safety reasons, they let staff know when they are going out and likely to return and where they will be. It was also noted that bathrooms and toilets are provided in sufficient numbers, conveniently located and are capable of being locked so as to assure service users privacy when conducting their toilet and ablutions. Other practices necessary to promote independence and choice, such as opening their own mail and opting in and out of group activities, were reported by service users as being a reality in the home. Service users involvement in housekeeping tasks is both recognised in their recovery programme as part of their treatment plan, i.e., to enable them to acquire or maintain independent living skills, and is outlined in the Service User Guide. These tasks are keeping their own bedroom clean and the upkeep of the communal area. House rules, with which service users are expected to comply, are set out in detail in the service user guide. This includes the rules on smoking in the Home, which are deemed reasonable. In practice, however, it was noted from the smell of cigarette smoke and the presence of a used ashtray, that some service users are smoking in their bedrooms. Since provisions in the Home include a smoking room, steps should be taken, on the grounds of fire safety, to dissuade service users from smoking in their bedrooms. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 14 In line with the Home’s purpose of enabling service users to maintain independent living skills, the catering arrangements are organised on a different basis to most other care homes. That is, service users are given a weekly provisions allowance from which they purchase and prepare their own meals. The kitchen has been equipped to facilitate this and where required staff support service users to plan menus and shop for the ingredients. This does not mean that there are no opportunities for them to dine communally. Staff prepared a communal meal each week (usually Sunday lunch) and, as observed at inspection, service users sometimes combine resources so that they can have a ‘takeaway’ meal of which they partake as a group. Both service users and staff confirmed that this arrangement works well and there was evidence in the form of literature in the kitchen to indicate that healthy eating is being promoted. Since no record is being kept of the food provided for service users, as required by regulation 17 (2), it is advised that this is included in each of their daily notes. It is also suggested that this is monitored and reviewed by a suitably qualified specialist, in relation to risk factors associated with obesity and low weight where relevant. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The Home is being run on a basis that ensures service users receive the physical and emotional health care that they need in ways that preserve their independence, comfort, privacy and dignity, but review of the procedure for administering medication is indicated. EVIDENCE: The Home specialises in the care and support of service users recovering from mental illness and all those resident at the time of inspection had this in common. The facilities and services are therefore principally geared towards addressing each individual’s mental health care needs. Since all the service users are active, they are supported in self-care and at the time of inspection none of them needed to be assisted with intimate care. Staff being present at the Home around the clock means that care can be provided flexibly thus avoiding service users being subjected to an institutionalised regime. In regard to routines and how these impact on choice, the Service User Guide suggests that the times when each services user rises in the morning and retires to bed at night is by agreement in respect of their individual plans. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 16 Further, the responsibility for the purchase of clothing, choice of dress and any personal style that he or she wishes to adopt is his or her responsibility. Service users whose views were sought confirmed that this is the case. Examination of service users records revealed that they are all registered with GPs and are receiving such specialist psychiatric and medical services, as they need. This includes monitoring of their general health and review of their medication. Those service users, who were seen, appeared to be in good health, clean, comfortably dressed and well looked after. It was inferred from this and the other arrangements outlined above that service users personal support and physical and emotional health needs are being met. Inspection of the management of medication at the Home showed that medicines are stored in a safe place and that recorded unused or discontinued supplies are returned to the pharmacy for safe disposal. There is a clear procedure for the administration of medication and information about the types normally prescribed for service users is readily accessible to staff. The medication records for September were checked and found to be up-to-date. The Manager reported that, at the time of inspection, only one service user had responsibility for keeping and administering his or her medication and that all service users have a secure cupboard in their bedrooms for this purpose. This shows that, subject to risk management, service users are encouraged to take control of their own health care including their medication regimen. Of concern was that since January 2005, the Incident Record shows three occasions when there were errors in the administration of medication and another recorded as a “near miss” more recently (14/7/05). This indicates the need for a timely review of this aspect of care. Also of concern was that the sole member of staff on duty for a substantial period during the inspection, who was during this time required to administer medication, had no training for this task. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 In this care home, service users are being looked after within a system in which they are encouraged to express their views and in which steps have been taken to protect them from abuse and neglect. EVIDENCE: The Manager explained that in terms of quality assurance and providing service users opportunities to voice their views and any concerns they might have, apart from approaching staff members or advocates, there are three processes in place to facilitate this. There are residents meetings, which are held every two weeks; there is the Quality Audit that is based on seven principles of good practice and includes surveys of service users’ views, and the complaints procedure, details of which are promoted to service users in the Service User Guide and the notice board at the Home. This was corroborated by relevant documents, which were seen and service users accounts of what happens at the Home. The Manager also advised of a recent survey of service users’ views, which is pending analysis by an independent person and the result of which the Manager was reminded to submit to the Commission. A record of complaints is being kept, as required, but shows that no formal complaints have been made since 2003. In relation to the protection of service users, the Home’s Statement of Purpose and the whistle blowing policy make clear that staff are expected through their own conduct and practice to ensure that service users are not abused, neglected, harmed or subjected to ill or unfavourable treatment. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 18 Furthermore, that they are under a duty to report any suspicion or evidence of any abuse. It was observed that a copy of No Secrets (Government paper on prevention and response to abuse) was available in the Home as was the local area Adult Protection Procedures. What was not immediately available was the Home’s own adult protection procedure and there was no evidence that staff members have received training in this regard. Following the inspection visit, one of the Team Leaders confirmed in a telephone contact that the Home does have its own adult protection procedure, which has now been found. Also that staff have received Vulnerable Adult Protection training, but this was some years ago since when new members have joined the staff team. No incidents of abuse were either reported or documented in any of the records checked during the inspection and none of the service users who were seen appeared in any way frightened, uncomfortable or isolated. From this it was concluded that there is no cause for concern about the protection of service users at the Home. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Service users are benefiting from living in this Home’s materially comfortable environment the facilities of which promote their independence, safeguard their privacy and contribute to healthy living. EVIDENCE: There has been no change to the premises except for the steps taken to address the requirements of the last inspection to replace broken tiles in one of the shower cubicles. The Home therefore continues to afford service users facilities that provide each of them a spacious bedroom, all of which are in good decorative order, adequately furnished and with fittings such as curtains, floor covering to ensure privacy and comfort. Communal facilities include: two sitting rooms one of which is designated the smoking area, a bathroom/shower room on each of the three floors and a toilet separate from that in the bathroom on the ground and first floors. There is a modern and well-equipped kitchen/dining area and suitable laundry facility for the number of service users accommodated. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 20 All these facilities are domestic in scale, are properly maintained, equipped and with due regard given to decoration, floor coverings, curtains and other adornments, combine to create a comfortable and home-like ambience. Ample outdoor space in the form of a large well kept rear garden is available to service users and the garden furniture provided cause it to be used as a valued additional facility, as observed at inspection. There were no obvious hazards inside the building and externally it appeared to be in sound condition. The most recent fire safety inspection of the Home carried out by Warwickshire Fire and Rescue Service concluded that the fire safety measures in place were “Satisfactory”. Arrangements are in place for addressing any immediate repairs as might be necessary and there is a maintenance programme, which includes refurbishment of one of the bathrooms as a priority. All areas of the Home were found in clean condition and there is a cleaning schedule and other hygiene measures such as provision of wash basins, soap and towels to encourage hand washing as means of controlling any spread of inspection, thereby minimising risk to service users’ health. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Care and support is being provided by a staff team committed to ensuring that service users’ mental health conditions are effectively managed so as to achieve recovery to pursue the kind of life that is likely to lead to the individual’s fulfilment. In this context, further developments are needed in risk assessing the lone staff working on some shifts and to validate staff’s competence through the National Vocational Qualifications (NVQ) accreditation process. EVIDENCE: From a sample of three staff members records, which was examined it was clear that staff appointed to the Home are selected because they have either had experience in working with adults with mental illness and are committed to the objects of the Home or have had related skills, interest and the motivation to develop through training. Some staff members therefore have a professional background in nursing or counselling. Staff members who were on duty during the inspection, and whose interactions with service users were observed, were courteous and respectful in their approach to service users. They were seen to guide and advise rather than direct service users and create a calm, harmonious atmosphere. All the service users present seemed entirely at ease and approached staff with confidence. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 22 This, in part, demonstrates that staff have the necessary personal attributes, have received, as reported, their induction and foundation training and are able to put these into effect. Disappointingly, only one member of staff currently has NVQ accreditation, but more encouragingly, the Manager confirmed that she has commenced the Level 4 Registered Manager Award and four other staff members are registered in the Level 3 programme in Care and Promoting Independence. It is essential that these members of staff continue to be supported to complete these training programmes if the requirement for 50 of care staff to achieve NVQ level 2 is to be met by the year’s end. Although the staff team is committed and motivated, the inspector was concerned that for much of the period of the inspection only one member of staff was on duty. Furthermore this member of staff reported having no training in administering medication, but being the sole person on duty was responsible for this task during the evening shift. This indicates the need for a risk assessment of the staff rostering arrangements, which should take account of the numbers and skill mix of staff on duty to ensure the effective running of the Home as specified in standard 33.2. In assessing whether care is being taken in vetting potential employees so as to protect service users, a check was made of the staff records mentioned above against the Home recruitment procedure. It was found that the procedure had been applied thus application forms, references and evidence of criminal records checks were on file. The Manager acknowledged that one of the requirements advanced at the last inspection for staff records to be kept in full as specified in the Schedules of regulations 7, 9, 17 and 19, e.g., proof of identity, has not been completely fulfilled. This is because some staff members have failed to provide them. It is imperative that steps be taken to address this matter so that there can be absolute confidence in the verity of all staff’s members’ credentials. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 The home continues to be well run so as to benefit service users whose care and circumstances have not been adversely affected by a recent change in the management arrangements. Service users’ health, safety and welfare are likely to be even more safeguarded by the recently introduced quality monitoring system. EVIDENCE: Owing to sickness and the subsequent resignation of the previous Registered Manager, a senior member of the Home’s staff has been acting in the capacity of Home Manager since March 2005. The Acting Manager advised that the post has been advertised and the Registered Person intends to ensure that whoever is appointed becomes registered at the earliest opportunity. Against this background standard 38 was only assessed in relation to the interim management arrangements, which are satisfactory. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 24 As earlier mentioned, a quality monitoring system has been introduced by the Registered Provider to compliment some of the existing monitoring arrangements such as the visits conducted in relation to regulation 26 and the contributions of the Advisory Group of stakeholders including service users representation. The new quality monitoring system is intended to assess the Home’s performance in all aspects of service users care and application of the principles that the Registered Person expects to underpin this. When considered against existing arrangements such as service users’ meetings and the opportunity that they have to express views about their care in individual counselling and guidance sessions with their key workers, it was deemed that sufficient is being done to satisfy the essential requirements of Standard 39. Examining the measures, which are being taken to control potential hazards in the Home and to ensure the safety of those therein, the inspector was satisfied that the Registered Person is taking the precautions set out in standard 42. That is, the Manager reported that care staff members have received training in First Aid, Lifting and Handling and in Food hygiene so that they can respond effectively to service users health and personal care needs. It was also observed from the records that there is a clear policy/procedure for the prevention and reporting of accidents and that fridge/freezer and hot water temperatures were being regulated to ensure food is stored safely and prevent scalding, respectively. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 X X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Moultrie Road Score X X 1 X Standard No 37 38 39 40 41 42 43 Score N/A X 3 X X 3 X DS0000004314.V261285.R01.S.doc Version 5.0 Page 26 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 YA20 Regulation 13 (2) Requirement The Registered Person must conduct a review of the custody and administration of medication at the Home for the purpose of ensuring that service users are not put at risk in future by being given the wrong medication. The Registered Person must ensure that all staff members who are required to administer medication or support service users to administer their own medication receive training to fit them to this safely. The Registered Person must proceed with the plans to ensure that the target of 50 of care staff (including agency staff) achieve NVQ level 2 by 2005 or soon thereafter by negotiation with the Commission. Timescale for action 09/12/05 2 YA20 13 (2) and 18 30/12/05 3 YA32 18 31/01/06 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 27 4 YA34 7, 9,17 and 19 The Registered Person must 31/01/06 ensure that all staff members’ records include all the information and documents specified in the Schedules for regulations 7, 9, 17 and 19. This supersedes requirement 5 of the last inspection, which has not been fulfilled (previous timescales 02/06/04 and 28/02/05. 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 28 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 YA2 Good Practice Recommendations Service users’ individual plans (or Recovery Plan) should be informed by an assessment covering the areas specified in standard 2.3 and clearly highlight the outcomes which are being worked towards, e.g., whether the service user is to be rehabilitated. Service users should be dissuaded from smoking in their bedrooms so as to reduce the risk of fire and in accordance with the Home’s own policy on smoking. Records should be kept of each service user’s diet in sufficient detail to enable periodic review by a suitably qualified person to establish whether the diet is nutritious and appropriate in relation to risk factors such as obesity and low weight. The Registered Person should ensure that the Home’s adult protection procedure is readily available to staff at all times and that the protection of vulnerable adults features as standard training in the staff induction and foundation programme. A risk assessment should be conducted in relation to the practice of a lone member of staff being on duty for some shifts. The risk assessment should take account and, if indicated, address any difficulties, which are likely to arise from the circumstances cited in standard 32.2. 2 3 YA16 YA17 4 YA23 5 YA33 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 3 Moultrie Road DS0000004314.V261285.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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