Inspection on 24/07/07 for 4 Maer Lane

This inspection was carried out on 24th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Maer Lane 09/07/08

4 Maer Lane 24/05/06

4 Maer Lane 23/02/06

4 Maer Lane 08/09/05

4 Maer Lane 12/10/04

4 Maer Lane 06/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 4 Maer Lane Market Drayton Shropshire TF9 3AL Lead Inspector Deborah Sharman KEY Unannounced Inspection 24th July 2007 09:30 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4 Maer Lane Address Market Drayton Shropshire TF9 3AL 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) 01630 698092 angelaj@tha.org.uk erikal@trident-ha.org.uk Trident Housing Association vacant post Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must demonstrate that the home is able to meet the individual needs of the older person accommodated through the provision of training and care planning documentation. 24th May 2006 Date of last inspection Brief Description of the Service: 4 Maer Lane is a purpose built residential home situated in Market Drayton, Shropshire. The home is owned and managed by Trident Housing Association. The Head Office is based in Birmingham. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of ten people with a learning disability to include one person over the age of 65. Equipment is available to support people with physical disabilities. Ms Angela Jones has recently been appointed as the manager and is yet to be registered with the CSCI. The home has a service user guide which it makes available to all stake holders and is available in an easy read version for those who may require it. The current range of fees is from £289 to £548 per month. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this unannounced key inspection. As the inspection was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection as ‘key’. These are the National Standards which significantly affect the experiences of care for people living at the home. Information about the performance of the home was collated in a number of ways. Prior to inspection the Manager provided the Commission for Social Care Inspection with written information and data about the home in their annual return. At the same time, using questionnaires, the Commission for Social Care Inspection sought the views of people living at the home and those of their relatives and other professionals associated with the home. These written comments were returned to the Inspector. Comments were received from all ten people living at the home, some of which were supported to reply by staff or family members. Written feedback was also received from three health professionals all of whom are involved with the home in different ways. In addition, since the last key inspection a further random inspection was carried out by CSCI in February 2007. The purpose was to assess progress towards meeting requirements made for improvement. This random inspection found a significant level of improvement with only one requirement remaining at the time that this key inspection was conducted. All of this information provided prior to inspection helped to formulate a focus and plan for this inspection and has helped in determining a judgement about the quality of care the home provides. During the course of the inspection that began at 9.30am and concluded at 6.00pm the Inspector used a variety of methods to make a judgement about how service users are cared for. The Manager was available throughout the day to provide information and answer questions as were staff. The Inspector interviewed two staff together and spoke less formally with the Deputy manager at lunchtime. The Inspector assessed the care provided to one service user in detail using care documentation and sampled aspects of care provided to two others. The Inspector also sampled a variety of other documentation related to the management of the care home such as training, recruitment, staff supervision, maintenance of the premises, accidents and complaints. The Inspector was able to tour the premises, ate lunch with service users, observed tea being served, observed two service users and staff preparing for a day trip to Llandudno, observed the administration of medication to service users and was there when two service users returned home from a weeks holiday to Spain. The Inspector was able to see how these service users responded to returning home and was able to talk to one of them about their holiday and their feelings about living at Maer Lane more generally. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 7 There is still an outstanding requirement in relation to the registration of the Manager with CSCI. This, the Manager states, has been delayed by the paperwork having been returned to her on a number of occasions. At this inspection she stated that her application was finally submitted successfully at the beginning of June 2007. However subsequent enquiries have shown that CSCI has not received an application and the situation continues to be unresolved and perplexing. Current service users indicate that they had no choice and insufficient information about moving into Maer Lane between 2001 and 2003. The Manager agreed that choice had been minimised by the need to re provide for a service that was closing at that time but is aware of how to meet the Standards in relation to admission to the home in the future. Staff are motivated and outcomes for service users are good. Standards in relation to ‘Staffing’ however now require the most attention for improvement. There are omissions in staff training, formal supervision provided to staff and evidence available to show that staff are always recruited safely was not provided satisfactorily. Recruitment documentation has been removed from the premises and is now held centrally. This left evidence that was contradictory in nature being faxed to inspection. Ultimately the conclusion was that a staff member had started in employment without a Criminal Record Bureau check having been carried out until 4 months after commencing in employment. Other safeguards were in place but how the evidence is made freely available to CSCI as part of the inspection process should be reviewed. Also maintenance documentation was found to be orderly with most of it available and readily accessible assuring the safety of the premises. Some omissions requiring attention were identified and need action to fully assure service users that the premises are fully maintained for safety. Discussion with staff identified that the only thing they felt could improve is the garden, which they felt needs weeding and developing. There were no urgent suggestions for improvement from service users, relatives or health professionals who responded to CSCI’s request for information. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. There have been no recent admissions to the home and current practice therefore cannot be judged. Existing service users however are not satisfied that they had sufficient information or choice about moving to Maer Lane. EVIDENCE: The home has a stable resident group and there have been no recent discharges or admissions to the home. In feedback to CSCI most current service users said that they were not provided with sufficient choice or information about moving in to this home when it originally opened. The Manager acknowledged this and is aware of ways to offer choice and provide information to any future prospective customers. Accessible brochures are available to support the admission process. The Manager is aware that both the Service User Guide and Statement of Purpose need to be reviewed. Contracts are in place between people living at the home and the Provider of service. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. Care plans and risk assessments provide staff with sufficient guidance to provide appropriate care. Staff know how to meet peoples needs and there is evidence that people living at Maer Lane are supported to make choices in their day to day lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Written care plans cover an extensive range of needs and describe how those needs are to be met for the individual based upon safety considerations, dignity, abilities and individual’s preference. Each aspect of the care plan is signed and regularly reviewed. The Inspector observed staff adhering to the plan of care to meet one service- user’s emotional needs. The manner in which care is reviewed is also clear. Daily records of care provided are detailed and evidence how the care plan has been implemented and where service users choices have been respected e.g. ‘She refused kippers for tea so had egg sandwiches.’ Monthly in house review meetings take place and 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 11 include the service user. Reviews with commissioners of service were also evidenced. Discussion with staff showed that staff are familiar with service users needs and how to meet their needs and preferences. A health professional told CSCI ‘Staff have a good rapport with clients and awareness of individual needs’ The Inspector observed staff adhering to safety measures put in place to minimise assessed risk to a service user. Staff for example, carry a pager which is activated when a bedroom door is opened. This system was seen to work and to receive a response from staff. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. Service users lead busy and active lives engaging in activities of choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users responded to CSCI’s questionnaire and all said they could do what they want to do in the daytime, during evenings and at weekends. Staff said that service users go out most days and go to bingo, the cinema, restaurants and pubs. One service user who likes fish and chips went to a restaurant for fish and chips with a friend for his birthday. Another service user is going with staff and his Mum to Blackpool for the day. Two service users went for the day to Llandudno on the day of inspection and all service users with the exception of one, for health reasons will have had a holiday this year. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 13 Two staff had supported two service users to holiday in Spain for a week and they arrived home during the course of the inspection. The service users were excited to be home but had had a lovely week and were keen to tell everyone about it. One service user told the Inspector that he had had a nice time, had slept in a hotel, had had nice food, had been on beach, had played ball in the pool and been on an aeroplane. Staff supported him to telephone his Mum upon his return. It is very evident that service users are supported to maintain contact with friends and family and staff are to be commended for the creative ways in which they support service users in this especially where it is difficult for relatives to maintain contact by visiting the home. For example a staff member helped a service user to trace his Mother who he found living in a nursing home and has visited her three times now. Another service user was supported to celebrate a special birthday with family who live a distance away and cannot travel. She was supported to stay in a hotel local to her family, which enabled her to celebrate her birthday with her family. An independent health professional who has contact with the home said ‘‘Staff are sensitive to client needs. They arrange contact visits with family, holidays and enable clients to access community services’. Also the home ‘supports individuals to access health needs and provides activities socially for clients families and others who may not be able to visit because of age or transport difficulties.’ Service users who want to attend church regularly. Staff confirmed that fresh food stocks are always available and that meals are of a good quality. Staff described a range of service users dietary needs and how they are expected to meet each person’s requirements. The Inspector ate lunch with service users two of whom were discreetly supported to eat. Service users sat together with staff for their meal, which was a calm and sociable occasion. Before leaving the Inspector observed tea being served which was healthy, colourful and generous in portion. Service users are provided with alternative meals if they wish. For example records showed ‘‘She refused kippers for tea so had egg sandwiches.’ 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. People’s personal care preferences and health needs are known and changes are responded to. Robust medication systems are in place to promote peoples health and to minimise the risk of error. Peoples’ health and safety is therefore safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are all well groomed and from discussion with staff it was clear that staff take pride in how they support service users to look their best. A staff member said ‘all service users look nice and buy clothes from nice shops, ladies legs are shaved, hair dyed and they have regular haircuts and there is no smell in the premises.’ Personal care preferences are included in plans of care and are known to staff. Staff were able to describe for example how one service user does not like to get water in her eyes and how they minimised this for her. This accorded with written guidance in the plan of care. Moving and handling is assessed with safe procedures in place supported by the availability of appropriate equipment 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 15 such as a lift, a manual hoist and for one service user, tracking hoists from bed to en suite facilities. Whether each service user prefers to bath or shower is known and each service user has their own bathing facility that meets their need and preference. The Organisation has heeded the advice of a physiotherapist and plans are being implemented to install a wet room for one service user for whom it was recognised that bathing was not as enjoyable as it could be. The service user group is equal in its male to female ratios but the care staff group is disproportionately female. The Manager is aware of this and would like to address the disparity. Health records for the service user case tracked shows regular routine health screening and treatment as well as prompt medical intervention when staff have recognised a change in health condition. Records also show that staff appreciate and are monitoring symptoms of her diagnosed condition. A health professional said ‘‘If there are any issues staff contact health professionals and have regular clinic appointments and GP visits’ and ‘Staff support all individuals to meet health care needs and follow up appointments’. Another health professional commented ‘I am pleased to see that recommendations are always followed’. There have been few accidents and those, which are recorded, show them to be minor in nature. A health professional said of the home ‘any issues re medication concerns are discussed at clinic meetings or with the GP who visits on a regular basis’. The Inspector observed staff administering medication, which they do in twos to minimise the risk of error. Practice observed was good. The Inspector also viewed medication records, protocols and storage. No areas for improvement were identified. Service users are receiving their medication as prescribed. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. The service is managed in the best interests of people who live at Maer Lane and there have been no complaints. Where vulnerabilities are evident action is taken to minimise risks to those living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Meetings with service users take place monthly and are minuted. There is a detailed complaints policy and a pictorial version available on display in the dining room. The home has not received any complaints and CSCI is not aware of any. All respondents to CSCI’s questionnaire with the exception of one said that they know how to complain should they need to. Adult protection procedures are available including a detailed physical intervention policy. The Manager and later staff confirmed that restraints are not used at Maer Lane. Although care plans do not explicitly include behaviour management guidance, this information is available to staff in behaviour risk assessments. Staff have a good understanding of how to avoid behaviours escalating. The Manager has experience of identifying and reporting incidents / allegations through the appropriate channels to ensure that vulnerable adults are protected as there have been 4 incidents largely between service users that have warranted the involvement of outside agencies. The Manager confirmed 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 17 that each incident had been considered by the Safeguarding Adults system and each had since been closed. One of the control measures to arise from such an incident was the door alarm system referred to earlier in this report. Two staff spoken to had both undertaken adult protection training and were aware of what abuse is and how they might become aware of it with service users who are none vocal. Service users financial records were not viewed but reconciliation systems were discussed with staff who felt that the system for managing service users monies is ‘absolutely robust’…’every penny has to be accounted for’. Staff said that service users monies are held individually, are checked by staff twice per day and that accounts are kept and all receipts retained. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. The clean and homely environment is maintained well and is kept under review. Changes are made where necessary to ensure that it continues to meet people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are spacious, clean and well equipped. Since the last inspection the premises have been redecorated and are bright and fresh. People competent to do so have carried out assessments and their advice is being acted upon to ensure that the premises and equipment continue to meet the needs of people living at the home. A wet room is being installed to ensure personal care for one service user is more comfortable and enjoyable and a made to measure easy chair is being provided too. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 19 Bedrooms are comfortable and personalised. The only thing to let them down was the non-provision of valances on the divan beds, which detracted slightly from the homely feel. A tour of the premises showed them to be safely managed on the whole with few immediate evident hazards. However, the Manager undertook to review unrestricted windows on the ground floor in the dining room and to take any action assessed as required. Also a flammable aerosol was found stored in a bathroom window in direct sunlight, which posed a fire / explosive hazard. Staff are aware of general infection control principles and personal protective equipment together with a clinical waste removal contract are in place. Mechanical sluice facilities are not available and staff are having to manually sluice. Action should be taken to minimise the risk of cross infection from the permanent storage of uncovered freshly laundered clothes next to the manual sluice. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is adequate. Staff ensure outcomes for service users are good and service users speak highly of staff with whom they have a good rapport. Some staffing systems however are lacking. Improvement would better support the safe provision of staff to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels are suitable and assessment of the rota shows that staffing ratios are being maintained. However current vacancies, long term sickness and generous holiday provision to permanent staff result in continuing high levels of dependency upon agency staff to fulfil the daily staffing quota. The manager finds the standard of agency staff to be good but the ongoing use of agency staff thwarts the provision of a consistent staff team to service users. The supervision records of 4 staff were sampled. Records show that staff have received between one and three supervisions in the last 12 month period rather that the national minimum of six. Staff reported feeling appropriately supported on a day-to-day basis. However two of the staff whose records were assessed are night staff whose working pattern tends to isolate them 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 21 more. The Manager acknowledged that it is difficult to schedule supervisions for night staff. This is compounded by the fact that whilst responsibility for carrying out supervision is divided between the Manager and Deputy Manager, supernumerary time for management tasks is not allocated to the Deputy Manager. Recruitment documentation has been removed from the premises and has been centralised since the last inspection. This slowed the inspection process and the new systems did not assure the Inspector that recruitment check systems are robust. Original Criminal Record Bureau checks are not retained in line with company policy. Two memos dated the day of inspection were faxed to the premises from Human Resources to confirm the date that a CRB had been received for the staff member sampled. Both memos contained contradictory dates and both indicated that the staff member had been employed for a significant time period before suitable checks were received. Whether they had been applied for prior to employment was not immediately clear. From the information faxed through it appeared however that a POVA first check had been carried out prior to the staff member starting in employment. This is a check undertaken against a national register to ensure the suitability of the candidate to work with vulnerable adults. The staff member had also been asked to self declare any previous convictions. The Manager obtains written assurances from the supplying agency that staff supplied are appropriately checked although this is not obtained from the first time the staff member is supplied. Training provided to the key worker of the service user case tracked was assessed. In line with national minimum standards it was evident that this staff member had received 5 days training in the previous 12 months. However a team analysis undertaken by the Manager shows a significant amount of training is due including training that is expected as a minimum as most training was last provided in 2003 and 2004. Within the previous twelve months, a newer member of staff had attended two lots of induction training, Mental Capacity Act training, Continence and medication training. The Managers training analysis for this staff member shows a significant amount of required training is outstanding e.g. Food Hygiene, Fire awareness, first aid, Moving and handling, health and safety and adult protection. Requirements in relation to training have not been made as a result of this inspection as the Manager through her own analysis is aware where there are omissions in training. Progress will however be kept under review. A workbook is available for new staff to complete as part of their induction. The Manager explained that the Learning Disability Award Framework induction training was stopped about 2 years ago. There was no evidence that the content of the current induction meets the required national standards. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 22 Candidates are not being encouraged to start and complete the induction within required timescales. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. The home is calm and orderly. Outcomes for service users are generally good although there are some omissions in management systems which require attention to minimise potential risks to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager confirmed that she resubmitted her application for registration to CSCI in June 2007. However enquiries made following this inspection again show no record of an application having been received. The Manager described a recent management restructure within the Company. She said she had always felt well supported and anticipates being as well 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 24 supported under the new arrangements. Likewise, staff at Maer Lane reported feeling well supported by the Manager describing her as ‘professional’ and able to drive the service forward. Detailed regulation 26 visit records are available, and the manager is required to develop an action plan for each where any matters requiring attention are identified. Staff meetings are held monthly and are timed to enable the manager to feedback Organisational issues to the staff team following management briefings that she attends. Staff meetings are minuted and also evidence service users and care practice as the focus. The Manager has completed a quality assurance tool for the first time to self assess the quality of the service provided. An action plan still needs to be developed from any matters arising from this exercise. The Manager however is mindful that the tool does not seek the feedback of service users or other parties and is considering devising a tool to address this gap. Premises risk assessments based upon the vulnerabilities of service users are in place but are brief. This includes within it consideration of the risk of fire but is felt to be insufficient and the Manager is required to review this in consultation with advice from the Fire Service. Weekly in house fire alarm system checks are in place but monthly emergency lighting checks are not being carried out routinely. Records, which are split over two files, show the last three tests to have been in January, April and May 2007, with tests for February, March, June and July not in evidence. The Manager agreed that the records need to be clearly maintained to encourage good practice. Contractors tests had been recently carried out however to assure that the systems are in safe working order. Records show that the last fire drill was July 2006. Staff stated one had been carried out in January 2007 but this had not been recorded. The Manager reported that the Fire officer last visited recently in January 2007 and was satisfied that no remedial action was required. Unrestricted ground floor windows, which were wide open on the day of inspection, have not been considered in the premises risk assessment. The Manager believed them to be restricted and undertook to review this. Data sheets are available for a range of hazardous chemicals used on the premises but the information in these has not been used to carry out assessments of risk. In addition neither data sheets nor associated risk assessments were in place for two chemical products randomly sampled from the COSHH cupboard. Toiletries are left out in bathroom areas including the bathroom area of a service user with dementia. The Manager did not believe this presented a risk currently but this must be kept under close review and the storage of aerosols in windows in direct sunlight must stop. Cold food storage, hot cooked food and water outlet temperatures are being taken and recorded and action is taken where temperatures do not comply with accepted safe ranges. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 25 Legionella tests to check the water quality and safety have not been carried out previously but the Manager confirmed that this had been organised for the week of inspection. First aid boxes are stocked and are available. The Manager is aware that only 25 of staff have received first aid awareness training and therefore not all shifts are attended by an appropriately qualified first aider. The Manager is trying to arrange more first aid training and should consider carrying out a risk assessment in the meantime. However, there have been few accidents on the premises and those that are recorded are minor in nature. Moving and handling equipment, portable electric appliances and gas appliances have all been serviced. A 5-year electrical safety certificate was not available and the manager did not believe there was one. It was concluded that as the premises were new in 2001 that the hard wiring certificate may have become due in 2006 and as such is now overdue. The Manager said she would look into this. The last inspection in February 2007 was a random inspection which found that all but one of the requirements issued for improvement had been met. With the exception of staff supervision improvements have been consistently maintained as evidenced at this inspection. Therefore the Commission for Social Care is confident that issues requiring action as identified at this inspection will be addressed in a timely manner. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 2 X 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 27 Yes, One. 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 YA37 Regulation 8 Requirement An application to register the newly appointed manager must be submitted to the CSCI. This requirement remains outstanding from the last inspection. Timescale for action of 31.3.07 has not been met. Timescale for action 31/08/07 2 YA42 23(4)(4a) In consultation with the Fire Authority, sufficient steps must be taken against the risk of fire and adequate arrangements for escape. This must include: • • • • Fire risk assessment Regular evidenced checks of emergency lighting Regular evidenced fire drills Immediate safe storage of aerosols. 31/08/07 New requirement arising from this inspection July 2007. 3 YA42 23(2)(b) Steps must be taken by someone competent to do so to assure the safety of electrical hard wiring within the premises. New requirement arising from this 30/09/07 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 28 inspection July 2007. 4 YA42 13(4)(C) Steps must be taken to: Ensure that unnecessary risks to the health and safety of service users (from hazardous chemicals and unrestricted windows) are identified and as far as possible eliminated, and Make suitable arrangements for the training of staff in first aid. New requirement arising from this inspection July 2007. 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA30 Good Practice Recommendations Steps should be taken to minimise the risk of cross infection from the permanent storage of uncovered clean laundered clothes next to the manual sluice in the laundry. New recommendation arising from this inspection July 2007. 2 YA34 Steps should be taken to review how recruitment documentation can be made satisfactorily available for inspection. New recommendation arising from this inspection July 2007. 3 YA35 Steps should be taken to review current induction training against standard 35.3 to ensure that as well as including safe working practices that it also includes training on the principles of care, the experiences and needs of the service user group and the particular requirements of the service setting. New recommendation arising from this inspection July 2007. 4 YA36 Staff should be provided with a minimum of 6 formal supervisions annually. New recommendation arising from this inspection July 2007. 5 YA39 Consideration should be given to including within the DS0000020766.V341302.R01.S.doc Version 5.2 Page 29 4 Maer Lane Quality Assurance tool methods for seeking and acting upon service user and third party feedback. New recommendation arising from this inspection July 2007. 4 Maer Lane DS0000020766.V341302.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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