Inspection on 09/07/08 for Mablethorpe Hall

This inspection was carried out on 9th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mablethorpe Hall 24/04/07

Mablethorpe Hall 26/09/06

Mablethorpe Hall 24/04/06

Mablethorpe Hall 25/01/06

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Mablethorpe Hall Alford Road Mablethorpe Lincs LN12 1PX Lead Inspector Elisabeth Pinder Unannounced Inspection 9th July 2008 09:00 X10029.doc Version 1.40 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 Mablethorpe Hall DS0000065213.V367993.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 Older People and 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. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mablethorpe Hall Address Alford Road Mablethorpe Lincs LN12 1PX 01507 472661 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) merilynking@yahoo.co.uk - cc micheleallen@btinternet.com Hamilton Community Homes Limited Mrs Merilyn King Care Home 24 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number disorder, excluding learning disability or of places dementia (11), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13) Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder, excluding learning disability or dementia, under 65 years of age (11) MD. Mental Disorder, excluding learning disability or dementia, who are over 65 years (13) MD(E). Dementia over 65 years of age (13) DE(E). Maximum number of service users to be accommodated is 24. 2. 3. 4. Date of last inspection 24th April 2007 Brief Description of the Service: Mablethorpe Hall is a care home providing personal care and accommodation for 24 younger adults and older people with mental health problems. The care home is owned and operated by a company, Hamilton Community Homes Limited, whose headquarters are in Leicester. The home is located on the outskirts of the coastal town of Mablethorpe. Transport, such as taxis, are required to access shops, hairdressers, pubs and the other amenities, which are in the town, over a mile away from the home. The home is set in its own grounds and is accessed over an un-adopted road, which also services other properties. Mablethorpe Hall has been adapted and extended to provide accommodation for people on two floors. The home is staffed as one unit, but comprises of two separate areas, being the main house and an annex. On the day of our visit fourteen people were living in the home. The current scale of charges at this home is from £364.00 to £411.00. Additional costs are made for hairdressing, chiropody, dentist, opticians, toiletries, newspapers and taking taxis to town. These are all private arrangements, individuals meet these costs. Information about the day-to-day operation of the home and fees, as well as a copy of the last inspection report, is available in the manager’s office. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms ‘we’ and ‘us’ refer to The Commission for Social Care Inspection (CSCI). The visit lasted approximately six hours and we took into account previous information held by us including the previous inspection report, their service history, monthly reports written by a representative of the company and records of any incidents that we had been notified of since the last inspection. The Commission are trying to improve the way that we engage with people who use services so that we gain a real understanding of their views and experiences of social care services. During this inspection we used a method of working where an ‘Expert by Experience’ visited the home as part of the inspection. An ‘Expert by Experience’ is a person who, because of their shared experience of using services, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert met and talked to a group of people on their own. Before we made our visit the providers had returned their Annual Quality Assurance Assessment (AQAA). This gave us important information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. Some specific information was included, which enabled us to send out surveys to people before we visited the service. Two staff surveys were returned and one relative survey. The main method used to carry out the inspection is called ‘case tracking’, this includes following the care of a sample of four people through their records and assessing their care. We spoke to two people who use the service and saw rooms of those people who said we could and to one staff member. The manager was present throughout the visit and the general outcomes of the visit were discussed with her. What the service does well: Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 6 A homely environment is provided for people who use this service and they are supported to increase their independence. Positive comments were it’s ‘alright living here’ and ‘I am quite happy here.’ There is a staff team who are committed and well trained. People who use the service generally felt that staff listened to them and feel comfortable to raise any concerns. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2 YA 1 & 3 OP standard 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People coming into this service have access to information to help them make a decision about moving into the home and procedures are in place to ensure people are only admitted after a full needs assessment has been carried out. EVIDENCE: Information about the home is available in the statement of purpose and service users’ guide, these tell people about the service. Both documents need Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 9 updating to include changes to the manager and staff, the change of address for reporting complaints to us and give more detail of how peoples’ differing needs such as religious and cultural will be met. A discussion held with the manager after the inspection confirmed that this is being done. The service user guide is available in picture format and the manager agreed to look into providing information in an audio format for people with sight disabilities. The previous inspection report was available in the office for people to access if they wish. Records of one person admitted in an emergency showed that information had been given from professionals on admission and the manager was working closely with them to develop a plan of care. There has not been any planned admissions since the last inspection, however, the manger said she will visit people to assess whether or not the service can meet their needs before agreeing their admission and the relevant documents were in place to support this. People who use the service said they had been able to visit the service prior to making a decision to stay. Generally, people said they were happy living in the home, one person told us it’s ‘alright living here.’ Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 OP 6, 9, 16, 18, 19 & 20 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from being involved in the planning and review of their care, however younger people would benefit further from having a person centred plan focusing on goals and aspirations. There is a lack of information to show that peoples’ capacity to make decisions has been fully considered which has the potential to deprive people of their rights. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three peoples’ records were checked and these gave clear information to enable staff to know about their individual needs and how to meet them. Care plans detail medical profiles and the requirement given during the last visit regarding medication records being kept up to date has been addressed. Records also detail any allergies and risk assessments have been written where risks have been identified and show peoples’ agreement and involvement in reviews. One relative/carer told us they were ‘very pleased with the care, could not wish for better’. The manager showed us she is in the process of reviewing all care plans and a discussion was held regarding information needed in the care plans for younger adults, for example, in relation to decision making and how their changing needs, aspirations and goals are considered. There was no reference to whether peoples’ capacity to make decisions has been considered when drawing up care plans, this is important in view of recent legislation which came into force in October 2007. Staff spoken to had very little knowledge of the Mental Capacity Act, although had a good knowledge of the needs of the people currently using the service. The manager confirmed that training for staff has commenced and an update is planned for August 2008. Information provided prior to the visit told us that there are both male and female carers employed, however, care plans did not show that people are given the choice as to whether they wish to have a male or female caring for them and the manager agreed to address this issue. There is a ‘key worker’ system giving staff some responsibilities for specific people who use the service and those people spoken to knew who their key worker was and said they get along with them. There is information about advocacy services available should people who use the service need it and it was noticed that one persons advocate was visiting during the inspection. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 OP 12, 13 15 & 17 YA Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported to have control of their daily lives within their capabilities. Activity arrangements are improving but these are limited and may not always meet individual recreational interests and wishes. The meals provided are well balanced and cater for peoples’ individual preferences and specific dietary needs. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 13 EVIDENCE: Comments from people who use the service were very mixed regarding opportunities to participate in a variety of activities and leisure interests. The report written by the Expert by Experience read ‘I thought that most of the residents who were evident in the rooms that I visited seemed to spend much of their time sitting alone and there was little conversation or people engaging with one another evident, although people did seem to be quite at ease’. People told the Expert by Experience that they go out to the shops for staff and one person said he felt he had a sense of responsibility as he was able to help staff by taking out the rubbish and managing his own room. He also said he had friends at the home. The Expert by Experience reported that generally people complained about there being little to do, one person described his life as ‘getting up, breakfast, dinner, tea and supper and going back to bed’. Another person said he would ‘like to get out more’ but because the care home doesn’t have transport this would be an issue. However, the manager said that taxis are available that charge £2 for each trip. People spoke about the lack of holiday opportunities and some said that finances were an issue. The manager told us that most people manage their own money and many choose to spend it on other things rather than leisure activities. We were also informed that one person has recently enrolled at the library and has attended a learning centre lecture on psychology. She also said that arrangements have been made for people to help out at voluntary organisations such as charity shops but they had refused to go on the day. Although there is a day centre in Mablethorpe no one uses this facility, however, the service is planning to access some short courses in the community due to commence in September. Books are available in one of the lounges and two people said ‘newspapers and teletext are a good link to the world at large’. People also said it was sometimes difficult to keep in contact with their family, often due to distance. One person said she would like to see her elderly father and the manager said she would arrange this. Records showed that health professionals visit and although one person said visits did not happen very often, records showed that weekly visits take place. During the visit some people were observed taking responsibility themselves for making their own drinks, helping staff to clear tables and shopping. Most people spoken to felt the food was good, the report written by the Expert by Experience reads ‘portions were given in relation to the person’s appetite Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 14 and need’. Staff were aware of people who had specific dietary needs and menus were available detailing the choices of meals available. The cook told us she consults regularly with people about the meals provided and menus are changed to show their choices, people spoken to confirmed this. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 OP 22 & 23 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service are protected by the procedures in place for handling complaints and allegations of abuse. EVIDENCE: Information taken from the AQAA tells us that people are given the complaints procedure and it was on display in the manager’s office. However, it does not include the correct contact details for us and the manager agreed to change it. There is a box on the wall for people to put in suggestions or minor concerns and people told us they feel able to raise issues with the manager or staff. Staff told us they know what to do should a complaint be made and have recently undertaken training in relation to safeguarding adults. No complaints or safeguarding referrals have been received since the previous inspection. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 16 None of the people spoken to had any concerns about the home and information received prior to the visit from one relative/carer told us they knew what to do should they wish to raise any concerns. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 &26 OP 24 & 30 YA Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People benefit from generally comfortable and safe accommodation, however some areas are in need of attention with regard to repair, décor and privacy. EVIDENCE: Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 18 People said they found their rooms to be comfortable and were able to arrange them to their liking and make them more personal with items of their own choice. The bedrooms of three people whose care was being followed were viewed and the wallpaper in one was noted to be very worn and, whilst the other room was nicely decorated, the lock was broken which prevented the person whose room it was from having confidence that her privacy was being respected as another person kept entering her room. The Expert by Experience’s report read ‘noticed that the building was somewhat dilapidated but did have a nice garden area with shrubs and flowers’. Although some windows on the first floor opened very wide, risk assessments had been completed in relation to the safety of people using these rooms, however, the manager should liaise with the health and safety officer to ensure these meet with legislation. Throughout the building there were a number of bare light bulbs and the manager agreed to ensure shades were fitted as soon as possible. It was also noted that the ground floor disabled toilet did not have a lock fitted therefore compromising privacy and dignity. Information provided in the AQAA told us that there is an on-going programme of redecoration and refurbishment and over the last year some of the improvements have included refurbishing bedrooms, purchasing new bedding, redecorating all ground floor toilets and creating a patio garden. An outside smoking shelter has been provided to meet with recent legislation. People living here have their own laundry baskets, bedding and towels to minimise the risk of cross infection. The service has visits periodically from an Environmental Health Officer and Fire Safety Officer. The last visit of the Environmental Health Officer raised a number of matters, which needed attention. Although these were not checked in detail on the day of the visit discussion with the cook established that these had been addressed. For example, new fly screens have been installed. Information provided also told us that there are policies and procedures in place for staff to refer to relating good hygiene and infection control practices. Staff spoken to said protective aprons and gloves are always available to use when needed. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 OP 32, 34 & 35 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for people living in this home. The service recognises the importance of training to ensure staff are knowledgeable and equipped to meet the needs of people living here. EVIDENCE: There are currently fourteen people living at Mablethorpe Hall and three members of care staff are on duty between the hours of 08:00 and 20:00. The manager’s hours are in addition to these and there are two wakeful night staff, however, during the next two weeks the manager was due to cover some of the night duty as one member of staff had left. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 20 The manager confirmed that recruitment is taking place and whilst we were there one of the people living in the home was asked if she would like to be on the interview panel. The Expert by Experience reported that three people engaged in reminiscence with her and she wondered how the need to discuss and make sense of the past was facilitated and on asking one person said staff were ‘helpful and available and always there to discuss problems when they have time’. Other comments regarding staff were positive and one person told us; ‘staff are good and I get on with them alright’. The expert by experience noticed some excellent interaction between a male carer and two male residents and said staff smiled a lot and seemed quite gentle and natural with people. No new staff have been employed since the previous inspection and records checked on the previous visit found staff were recruited using safe procedures. All are given copies of the General Social Care Council Codes of Practice, which sets out responsibilities as care workers looking after vulnerable adults. Training records confirmed that over 50 of staff have achieved a nationally recognised vocational award in care and the service has registered with Skills for Care Council for induction training. One member of staff spoken to confirmed he had received relevant training including in-house mental health training from the manager, first-aid, infection control, food hygiene and safeguarding adults. He told us he had previously undertaken training relating to challenging behaviour but feels he would benefit from an update in this. The service is currently without a cleaner and staff said that cleaning duties have been allocated to them, however, no additional staff are on duty to take this into account. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 22 31, 33, 35 & 38 OP 37, 39 & 42 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service is being well managed and there are opportunities to ensure peoples’ views about the service are sought in order to monitor and develop the quality of the care provided. EVIDENCE: Since the previous inspection a new manager has been appointed and she was registered in February of this year. The manager is a registered nurse in mental health and is planning to commence the registered managers award. Since starting in the home she has undertaken a lot of work to ensure standards are met including reviewing all policies and procedures. Staff said they found the manager to be approachable, available and she will listen to their opinions, and offer support to do their job. Quality assurance questionnaires have recently been sent to residents and relatives and the manager now plans to send them out to other stakeholders including the community mental health team. Once these have been returned a report reviewing the quality of care will be written and sent to us. The service uses the Department of Health guide ‘Essential Steps’ to access the current infection control management and health and safety policies are in place. Records showed that fire equipment checks and fire evacuation drills are carried out regularly and fire safety training is due this month. Information provided prior to the visit told us that equipment and appliances are regularly serviced and a sample of records checked on the day confirmed this. Accident/incident records are in place and we are informed of any incidents that require reporting. Up to date and accurate records are kept of residents’ finances and during the visit the manager was seen helping a person with changes to their disability allowance. Records of visits made to the service by a representative from the company were seen, the last visit being undertaken on 12/06/08. However, the report was not yet available in the home and the manager said this would be sent directly to us. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 2 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 [1] Mental capacity Act 2007 Requirement Care plans for younger adults must focus on changing needs, goals and aspirations to ensure people know their needs will be met. Care plans must take into consideration the Mental Capacity Act 2007 in order to ensure people are not deprived of their rights. Appropriate activities and leisure opportunities for people to participate in must be provided to meet individual needs. Locks must be provided on toilet doors and people must be offered the facility of a lock on their bedroom door to ensure privacy and dignity are respected. All parts of the home must be kept clean and reasonably decorated to provide people with clean, well-maintained and comfortable surroundings. Timescale for action 31/08/08 2. OP12 16[2][n] 30/09/08 3. OP24 12[4][a] 31/08/08 4. OP19 23[2] d 30/09/08 Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 25 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. 4. Refer to Standard OP10 OP16 YA24 OP30 Good Practice Recommendations Care plans should detail peoples’ choice and wishes regarding care being given by male or female staff. The complaints procedure should be updated to show the change of address for the Commission. The manager should consult with the health and safety officer regarding the opening of windows on both the ground and first floor of the building. Staff training should include an up-date in challenging behaviour to ensure staff feel confident to carry out their role. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI. Mablethorpe Hall DS0000065213.V367993.R01.S.doc Version 5.2 Page 27 - 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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