Inspection on 10/07/06 for 5 Barth Close (Royal Mencap Society)

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Barth Close (Royal Mencap... 12/07/07

5 Barth Close (Royal Mencap... 27/09/05

5 Barth Close (Royal Mencap... 21/06/05

5 Barth Close (Royal Mencap... 16/12/04

5 Barth Close (Royal Mencap... 12/08/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Barth Close, 5 (Royal Mencap Society) 5 Barth Close Great Oakley Corby Northants NN18 8LU Lead Inspector Mrs Kathy Jones Unannounced Inspection 10th July 2006 08:00 Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.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. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barth Close, 5 (Royal Mencap Society) Address 5 Barth Close Great Oakley Corby Northants NN18 8LU 01536 460718 01536 741204 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) Royal Mencap Society Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: The home 5 Barth Close provides personal care and accommodation for 5 younger adults within the category of Learning Disability. The building is rented from a housing association with the home and the services provided being managed by the MENCAP organisation. 5 Barth Close is located within the Great Oakley residential area of the town of Corby and is adjacent to a health centre with pharmacy and close to a national superstore. The home was newly purpose built and opened in April 2000 and is indistinguishable in design from other houses in the area. All the rooms within the home are for single occupation and without en-suite facilities. Communal areas consist of a small lounge and a kitchen with a small dining area. The garden is large in comparison with similar private residential properties in the immediate area. Information about fees charged to funding bodies was not available at the time of this inspection. In addition to these fees, residents pay between £62.45 and £75.40 per week. The fees include personal care, accommodation, meals, laundry and a seven day holiday. Additional charges include chiropody, toiletries, clothing and travel. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The review of evidence and pre-inspection planning was carried out over the period of half a day and involved reviewing the reports of the last two statutory inspections, the latest carried out in September 2005. The service history was reviewed, which details all contact with the home including notifications of events reported by the home, complaints, protection of vulnerable adults investigations and telephone calls. A temporary manager from another home submitted a pre-inspection questionnaire. No comment cards from relatives/visitors, health professionals or residents’ were received prior to this inspection. The information gathered assisted with planning the particular areas to be inspected during the visit. The unannounced inspection visit covered the morning and early afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The inspector observed the early morning routine and spent time with them prior to them attending day centre. Conversations were limited due to communication difficulties and findings of this inspection in relation to residents’ experiences are based mainly on observations. One resident was happy to show the inspector her room as part of the assessment of the environment. The management of residents’ medication was reviewed. Staff training was discussed with staff and two files for newly recruited staff were reviewed to check the adequacy of the recruitment process. This unannounced inspection happened to take place on the first working day of the newly appointed acting manager. All findings of the inspection were discussed with the acting manager who assisted in locating records and has used the inspection process effectively in identifying issues to be addressed. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.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: Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 7 Review of a sample of residents’ care plans identified that they had not been kept up to date, were not reflective of all current needs and did not incorporate all of the advice given by professionals. One particular concern was a care plan in place, which indicated poor/abusive practices. Discussion with staff confirmed that these practices were changed following an investigation and advice from the community nurse however the care plan had not been updated. As care plans are documents used to guide staff in providing consistent care based on residents’ preferences and professional advice it was of concern that a new or agency member of staff could have followed the plan. Some good work seems to have taken place in developing tools to assist residents’ with decision making and understanding their daily routines, however the tools, which are laminated pictures, were not in use. Progress of referrals made to health professionals appeared to require closer monitoring to ensure appropriate advice is sought as soon as possible. For example a referral had been made to a psychologist in October 2005 and there was no evidence of an appointment some nine months later. Records need to be in place to confirm that all advice has been acted on, such as advice to monitor a resident’s fluid intake. The acting manager is going to review the medication system, as some of the processes were not clear particularly in relation to medication prescribed to be given at lunch time when residents’ are at day centre. Previous inspection reports have highlighted difficulties with the limited amount of communal space and residents’ differing needs. There is just one small lounge and a small dining/kitchen and advice has been given to consider providing more space. This has not yet occurred however the inspector was informed that work is to commence on a conservatory in September 2006. Staff have not received training to meet the specific needs of residents such as autism and epilepsy. It was also identified that a resident uses makaton to communicate and staff have not had training in the use of this method of communication. 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. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The admission process provides assurances that the needs of residents’ entering the home can be met. EVIDENCE: It was identified at the previous inspection that although there were copies of social services assessments, carried out prior to a resident being admitted, there was no evidence of how the organisation had assessed their ability to meet the prospective residents’ needs. A requirement was made to develop an assessment tool to assist this process. The acting manager confirmed that Mencap have an assessment tool and a clear admission procedure which would be followed to ensure that they could demonstrate how an individuals needs would be met. As no new residents have been admitted since the last inspection it was not possible to fully review the admission process. However the acting manager confirmed the process would include ensuring that staff have the right skills and training and that the needs and views of existing residents are taken into account. Prospective residents’ would also make several visits to the home to help them decide if they wished to move in. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 10 Discussion during the inspection identified that the new acting manager has recognised the need to assess how residents’ needs are currently met to ensure that they are properly supported in all areas. Copies of terms and conditions were on residents’ files however it was identified that the charges on one sample checked did not correspond with charges actually being made to the resident. Records indicated that new terms and conditions had not been agreed when charges were increased. The reasons for the difference in charges for individual residents were not apparent from the information available. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 11 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, 9 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Care planning processes do not identify and support residents’ personal goals and areas of risk, and failure to review and update care plans based on good and safe care practices puts residents at risk. EVIDENCE: A sample check of care plans for three residents’ was carried out with the acting manager. Care files were securely stored and accessible to staff however were kept in a way that did not encourage and enable staff to use them as a working tool to guide the care provided. Some care plans viewed were very detailed and provided some good clear information about how individual needs and preferences were to be met. However from observations and discussions during the inspection it became apparent that care plans had not been kept up to date and were unreliable in guiding staff in the actions they need to take to meet residents’ needs. For Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 12 example information in a continence care plan had not been updated following advice from the continence nurse. Review of one resident’s care file highlighted clearly the risks associated with care plans not being reviewed and kept up to date. A care plan was in place on the file, which indicated the use of care practices which could be considered to be abusive, identifying the use of restraint as a method of attending to a personal care need. Discussion confirmed that following an investigation at the end of last year, advice was sought from the community learning disability nurse and more appropriate practices are now in place, which take account of the resident’s needs and rights. Current staff are aware of the changed practices however as the care plan had not been changed there was a risk that new staff may have followed the guidance given. The acting manager removed this plan from the file during the inspection to remove this risk. Requirements relating to care planning have been made in the last three inspection reports particularly identifying the need to include residents’ personal goals and demonstrate opportunities for their personal development. It is of concern that there was little evidence of action being taken to meet the requirements. One resident’s care file identified a plan to assist a resident in communicating their needs to staff through the use of makaton. While this was broken down into small achievable steps there was no evidence this had been implemented. The inspector was satisfied that the new acting manager was identifying the same issues and sees care planning as a priority to support residents’ care. The acting manager also confirmed that residents’ would be fully involved in the care planning process. There was no evidence of strategies based on residents’ individual needs to support them in making informed decisions and taking responsible risks. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 13 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, 17 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Residents’ receive support in accessing community and leisure activities and maintaining contact with their families however better planning to meet individual needs may reduce the risk of their rights being restricted. EVIDENCE: All residents’ attend day services; one resident said that they found it “boring”. Discussion with the acting manager identified that alternatives will continue to be explored based on the resident’s abilities and the options available. Discussion with residents’ and staff confirm that residents’ have access to community facilities and leisure activities. The experience and number of staff on duty and the particular residents’ in the home determine the choice of activities. The acting manager intends to review residents’ needs and preferences as part of the care planning process and base the staffing arrangements on this to ensure residents’ needs are fully met. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 14 Records show that residents’ religious needs are respected and review of one file showed that a resident is supported to attend church services. Residents’ enjoyed showing the inspector photographs of a holiday. Staff advised that two residents had been away on holiday very recently. Laminated photographs and pictures of daily activities that residents’ are involved in had been made to assist residents’ in understanding their daily routines. A resident showed the inspector a board in their bedroom which contained some of the pictures however it was identified that the pictures did not reflect the routine for that particular day. One resident talked to the inspector about a regular visit to her mother. It was evident through the inspection that all residents’ are encouraged and supported to visit and maintain links with their families. Observations and discussion during the inspection indicated that there are some limitations on residents’ rights in relation to daily routines, access to all parts of the home and staff time due to the differing needs, personalities and behaviours of other residents’. A resident showed the inspector photographs of different meals that are provided in the home and was able to indicate preferences. The process for planning the meals was not confirmed during the inspection however the acting manager has confirmed that she will be ensuring that all residents’ are involved in making choices and that the meals form part of a balanced diet. No cultural or religious needs and preferences have been identified in relation to diets. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 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): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Residents are supported with their personal care, and health care services are accessed on their behalf. However more thorough assessment, review of needs, care planning and monitoring would assist in meeting health care needs more fully. EVIDENCE: A sample of residents’ personal care plans contained a good level of detail and identified their individual needs and preferences. As previously highlighted, care, needs to be taken to ensure that these are reviewed regularly and that the ones used to guide staff are up to date. Discussion with staff and observations indicated that they are respectful of residents’ privacy and dignity and personal care was provided in residents’ rooms. Discussion with staff and observations indicated that they are caring and keen to work in the best interests of residents’. Records showed that various health professionals have been accessed on behalf of residents’ for example the general practitioner, community nurse, Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 16 incontinence adviser, dentist, podiatrist and speech therapist. While it was evident that some of the advice given had been acted on though not recorded in the care plans this was not so in all cases. There was no evidence that a resident’s fluid intake was being monitored as advised. There was also no evidence of any checks being made on the progress of a referral to a psychologist made in October 2005. At the time the medication system was checked no staff were on duty to clarify the process and the acting manager had just started work in the home that day and was therefore not familiar with practices in the home. A sample check of the medication system identified that some areas need to be addressed to safeguard residents and staff. , Some medication is supplied in a blister pack format which clearly identifies the times and dosage of medication to be given. A sample check indicated that this medication is being given as directed and staff sign to confirm this. It was not clear from the system how residents receive any prescribed lunchtime medication as they are at day centre during this period. One resident is prescribed liquid medication for epilepsy three times a day including lunchtime, however it was not clear who administers this and at what time. A medication prescribed for 2 x 5ml spoons and up to 4 x 5ml spoons did not contain any guidance for staff as to what would determine the increased dose. The acting manager confirmed that she would review the medication procedures and take advice from the pharmacist and check staff training to ensure safe procedures are in put place. Staff had earlier advised that the pharmacist was due to carry out an audit of the system later in the week. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The organisation has demonstrated that they take complaints and any allegations of abuse seriously, however failure to update care plans based on investigation findings could leave residents’ at risk of abusive practices. EVIDENCE: At the time of the previous inspection a complaint was in the process of being investigated by Mencap. The Commission for Social Care Inspection were also informed of the complaint, which related to care practices and the general organisation of the home. A protection of vulnerable adults referral was made to social services and following a multi-disciplinary strategy meeting this was investigated as part of the complaint being investigated by Mencap. The investigation identified some poor care practices and general management issues in the home and action was taken by the organisation to improve care practices and outcomes for residents’. As identified under the individual needs and choices section of this report care practices were changed based on the advice of other professionals. The inspector was satisfied from discussion with staff that the advice was being followed however failure to check the care plan had been updated could have resulted in a repeat of the poor practices. The Commission for Social Care Inspection have received no complaints and there are no entries recorded in the complaint record in the home of other complaints. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 18 Discussion with staff during the inspection confirmed that staff have received training in safeguarding vulnerable adults and that they were aware of their individual responsibilities for reporting any concerns. Details of the complaint procedure are displayed in the hall. The acting manager advised that work is currently being carried out on producing a format for the complaints procedure, which will be more accessible to residents’. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The home was clean and comfortable however the limited communal space does not fully meet the differing needs of residents’. EVIDENCE: The home looks like any large family home in the area. Communal areas consist of a small lounge and a kitchen diner. Arrangements are in place to decorate and refurbish as required. Staff advised that permission had been given to order new furniture for the lounge and samples of flooring had been ordered for two residents’ to choose new flooring for their rooms. Concerns have been raised about the limited space and the impact this has on residents’ who have a range of different needs. The inspector was advised that work is due to commence on a new conservatory in September 2006, which will provide more communal space. There is a large enclosed garden which residents’ are able to access freely. One resident was using a swing in the garden and appeared to be enjoying some space away from the others. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 20 A resident showed the inspector their room, which demonstrated that residents’ are encouraged to personalise their rooms. The resident had chosen the colour scheme and discussed colour preferences for next time the room was decorated. All areas of the home were clean and hygienic. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Residents’ are cared for by staff that are committed to them and to developing their knowledge and skills to meet their needs. However specific training needs to be provided to meet the specialist needs of residents. EVIDENCE: Observations during the inspection confirmed that staff, have built up good relationships with residents’. The staff team appear very committed to the residents’ and to the home. For several months the home has been without a permanent manager and there have been some staff vacancies. Indications were that they have worked together to ensure that this has not impacted too much on residents’. The acting manager advised that three new staff have been recruited which will bring them up to their full complement of staff. There are two staff on duty in the home with five residents. Observations and discussions during the inspection indicated that there were times where it was difficult for staff to meet the differing needs of residents. It was however acknowledged that the presence of an inspector and a new manager could have had an impact on the situation. Some difficulties in meeting differing needs and preferences in relation to leisure activities outside the home were discussed. It was agreed Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 22 that the acting manager would monitor the adequacy of the staffing levels in line with residents needs. A sample check of staff files confirmed that references and criminal record bureau clearances are received prior to staff working in the home providing protection for residents. The acting manager confirmed that when recruiting new staff it would be her intention to involve residents’ in the interview process and seek their views. Induction training records were not available at the time of the inspection. The acting manager confirmed that she would use the Mencap induction and foundation training which meets the sector skills criteria to induct new staff. It was confirmed that this training is specifically for working with people with a learning disability. This training helps to ensure that staff have a basic understanding of providing care and support to people living in the home. Three staff currently hold a National Vocational Qualification at level 2 (NVQ2) in care, which covers basic care practices. The ratio of staff holding a qualification in care is currently just slightly below the recommended minimum of 50 . Staff have received training in various areas, which include: equality and diversity, adult protection, challenging behaviour, medication and first aid. It was identified that staff have not received any training on autism or epilepsy to meet the specific needs of some residents however staff were keen to undertake additional training. One resident uses makaton to communicate however staff have not had training in the use of this method of communication. The acting manager had already identified this and intends to arrange additional training. Records show that the majority of staff have received a recent one to one supervision session with a manager, which provides opportunities to discuss training needs and how residents’ needs are being met. The acting manager plans to hold a staff meeting and individual supervision sessions as soon as possible with staff to provide them with opportunities to raise any issues and make suggestions for any improvements to the care provided. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Arrangements are in place to manage the home in the best interests of residents’. EVIDENCE: Standard 31, which is one of the key standards, has not been assessed, as the home does not currently have a registered manager. Temporary management support has been provided from other Mencap homes in the area overseen by an area manager. A permanent manager has now been appointed and as highlighted in the report happened to start work on the day of this unannounced inspection. As the manager has not yet been registered with the Commission for Social Care Inspection, she is referred to as the acting manager in this report. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 24 While some shortfalls have been identified in this report, which relate to the management of the home it is acknowledged that a new permanent manager is now in post. Throughout the inspection the acting manager was very cooperative with the inspection process and demonstrated a commitment to the provision of a good standard of care and support to residents’. As the acting manager was unfamiliar with what had taken place in this particular home in relation to quality assurance some of the Mencap processes that she intends to put in place were discussed. Questionnaires are sent annually to residents’ who complete them with someone who is not connected with the home. Responses are forwarded to a central office within Mencap who collate them and transfer them into a regional development plan. The acting manager also advised that Mencap have developed a continuous improvement plan for each service. Area managers’ visit each home every month and report on the findings of the visit. The acting manager confirmed that residents’ views would be sought on an ongoing basis through meetings and ongoing discussion with them. The pre-inspection questionnaire submitted by a registered manager from another home indicates that relevant maintenance checks and servicing of equipment is carried out. There were some omissions in information supplied such as the date an electrical wiring certificate was issued. The questionnaire identifies that the manager had some difficulty collating all of the information from the records in the home and there were some gaps in information. The acting manager has confirmed that she will check to ensure that everything is up to date. Staff confirmed that they receive training in safe working practices such as food hygiene and first aid. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X N/A X 3 X X 3 X Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 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 YA6 Regulation 12 (1) (a, b), (2), (3) Requirement Care plans must be kept up to date and be reflective of all residents’ current needs and the actions required of staff to meet them. Risk assessments must be in place to guide Staff in the management of specific behaviours. (This requirement is outstanding from the inspection of 27.09.05) Timescale for action 15/09/06 2. YA9 12 (1) (a, b), (2), (3) 15/09/06 3. YA19 YA18 YA6 YA23 12 (1) (a, b) 4. 5. YA32 Care plans must incorporate 15/09/06 professional advice given as to the actions required of staff to meet residents’ needs. 13 (6) All records in place to guide staff 15/09/06 must be reviewed to ensure that there is no risk of poor or abusive care practices being advocated. 18 (1) (c ) Staff must receive training to 30/11/06 (i) meet the specific needs of residents’ including autism, epilepsy and the use of makaton. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 27 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. 2. 3. Refer to Standard YA6 YA19 YA20 Good Practice Recommendations Care plans should include personal goals and opportunities for personal development and decision making. Records must demonstrate that professional advice has been followed. For example fluid monitoring. A full review of medication administration should be carried out to ensure that practices are in line with current good practice. Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V303677.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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