Inspection on 07/02/07 for Mandela House

This inspection was carried out on 7th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mandela House 16/02/06

Mandela House 20/07/05

Mandela House 07/02/05

Mandela House 26/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mandela House 13 Vicarage Road Cromer Norfolk NR27 9DQ Lead Inspector Mrs Lella Andrews Key Unannounced 7th February 2007 02:30 Mandela House DS0000027484.V330071.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 Mandela House DS0000027484.V330071.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. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandela House Address 13 Vicarage Road Cromer Norfolk NR27 9DQ 01263 514747 01603 279529 m.jeesal@virgin.net www.jeesal.org Jeesal Residential Care Services Limited Mrs Sally Subramaniam Mrs Shirley Luke Care Home 8 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) Category(ies) of Learning disability (8) registration, with number of places Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Mandela House is a large terraced house in the town of Cromer. It is located in a residential area which is close to the town centre and to the seafront. The Home is registered to provide a service for up to eight adults with a learning disability. The Home is owned and managed by Jeesal Residential Care Services Ltd. The accommodation is on three floors and there is no passenger lift. The service users all have a single bedroom. The Home has a small garden to the rear. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information about the Home that has been gathered since the last Inspection which includes an unannounced visit to the Home on the 7th February 2007. During the visit the Inspector was shown around the communal areas of the Home, spoke to tenants and staff, looked at records and spent time discussing issues with the deputy manager. The Manager was not present during the visit to the Home. The Inspectors presence in the Home caused some considerable distress to one of the tenants and so the visit only lasted for just over 2 hours. The report also contains information gathered from the pre inspection questionnaire which was completed by the Manager and from six comment cards received from the tenants, assisted by staff, and one comment card received from a relative. The Inspector also spoke to the Manager by telephone to clarify some issues after the visit to the Home. All of the tenants comment cards state that they like living at the Home and that they feel well cared for. Additional comments included the following: “I like my room” “I like everything” “I like the people” There are currently six tenants living at the Home with two vacancies. The fees for the Home are individual agreed depending on the needs of the tenants. These currently range from £950.00 to £1,400 per week. What the service does well: The Home provides comfortable and homely accommodation for the tenants The Home is well managed by the Manager and deputy manager, who tenants and staff find approachable. The care plans and risk assessments are detailed and contain good information for staff about how to meet tenants needs. The views of the tenants are sought in a variety of ways. The tenants take part in a lot of activities, both educational and leisure. The staff receive good training and support to help them carry out their roles effectively. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 6 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. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has appropriate admission and assessment procedures in place. EVIDENCE: The Home currently has two vacancies. The Home has effective admission and assessment procedures in place which will be used in the event of an enquiry about the vacancies. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The tenants are supported to make their own decisions in as many areas as possible. The care plans contain detailed guidance for staff about how to meet the tenants needs. Risks are recognised and assessed appropriately. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 10 EVIDENCE: One of the care plans was looked at. This contains a great deal of information about the needs of the tenant and guidance for staff about how to meet these needs. The deputy manager said that they have recently reviewed the format of the care plans and have made some changes so that there is now a shorter version which contains the necessary day to day information which is important for staff to know. These care plans are kept downstairs so that the tenants have access to them with the additional information kept in the sleep in room which staff can easily access if they need to. The new versions of the care plan was seen for one of the tenants and this contains updated care plans and risk assessments. The deputy manager said that the Manager is also in the process of updating the “pen pictures” for each of the tenants. The deputy manager is in the process of completing information about the daily routines for the tenants and also the key worker responsibilities for each of the tenants. An example of these documents were seen and both contain detailed information relating to the individual needs and choices/preferences of the tenant. The care plans contain monthly reviews which have been produced using words and symbols to make it easier for the tenants to understand. This is good practice. The tenants comment cards all state that they are aware of their care plan. The care plans contain detailed risk assessments which cover a range of issues relevant to each tenant. There is guidance for staff with regard to identified risks. The tenants comment cards indicate that tenants are assisted with their personal finances. The tenants have a financial care plan which describes the arrangements in place for assisting tenants to look after their money. Whilst an audit was not carried out for all arrangements in place a check was taken of the cash held for one of the tenants against the daily expenditure records. It was also noted that records of cheques are kept with copies of the cheques. There are also records relating to fees and any other charges, such as mileage. The tenants are supported to make their own decisions about issues. Tenants and staff gave examples of how this is put into practice. Staff recognise the importance of effective communication and how improvements in this area can enable tenants to make more choices. The Home now has a communication board with details of the daily activities for each tenant and also a board with information about which staff are on duty, on holiday or training. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 11 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 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Tenants are supported to take part in a range of educational, work and leisure activities Tenants are able to make choices about how they spend their time Tenants are involved in choosing meals, shopping and cooking Relatives are encouraged to visit Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 12 EVIDENCE: All of the tenants comment cards state that there are lots of things to do. The communication board shows clearly what each tenant has planned for that day although staff said that they are also given the choice on each day in case they have changed their mind about what they had planned to do. The care plans contain information about the individuals likes and dislikes with regard to activities, both educational and leisure. Tenants have a busy week with attendance at a range of day services, adult education classes, horticulture and more leisure style activities such as going for walks, shopping and meals out. Staff said that the staffing levels are adequate to enable tenants to attend the activities of their choosing. They said that tenants rarely choose to go out in the evenings during the week as they have been busy during the day. At weekends the activities are much more leisure based, such as going to the pub, out for meals, to the cinema. Some tenants visit relatives at weekends. The Home has a vehicle for the tenants use and is also situated within walking distance of the town of Cromer and its facilities. One of the tenants told the Inspector about their family visiting and how often this happens. The care plans contain information about the arrangements in place for tenants to maintain contact with family and friends. The relatives comment card states that they are kept informed of important matters relating to their relative and that they are satisfied with the overall care provided. The staff are aware of the rights of the tenants and recognise the need to respect that it is the tenants home and to support them to make choices about how they spend their time. A tenants meeting is held every evening. This is now a more informal discussion rather than a formal meeting with minutes taken. The tenants make their own choices about meals. One of the tenants said that they enjoy their meals and that they choose what to have. Staff said that there can be occasions when three different meals are prepared. The menu is displayed in the dining room using words and photographs to enable as many tenants as possible to understand it. Tenants are involved in the household tasks such as shopping, cooking and clearing up after meals. Some of the tenants make their own drinks and snacks, depending on the outcome of risk assessments. One of the tenants has their own kettle and fridge in their bedroom. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of the tenants are met Medication is managed effectively EVIDENCE: The care plans contain detailed information relating to the personal and healthcare needs of the tenants. Records of appointments are kept and care plans updated as necessary following any changes to the tenants needs. All of the tenants comment cards state that they feel well cared for. They also state that they see the doctor and dentist. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 14 The staff are aware of the personal care needs of the tenants. Staff were seen to support a tenant sensitively during a difficult situation. Tenants said that they can get up and go to bed when they want to and one said that they have a lie in at weekends. Tenants are clearly encouraged to develop their own sense of style with regard to clothes and hairstyles. The medication system was seen. Medication is stored appropriately and records are kept of receipt of medication into the Home and of the administration. Staff said that they adhere to the Homes policy of two staff being involved in the administration of medication. All staff have received medication training. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 15 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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The tenants feel that they can raise any concerns they might have Staff receive relevant training and policies and procedures are in place to protect the tenants from abuse EVIDENCE: The tenants comment cards all state that the tenants know who to talk to if they are unhappy about something. The complaints procedure is available in words and symbols. The tenants are given opportunities to raise any concerns in a variety of ways. For example, tenants meet with their key worker on a monthly basis to review their care plan, they have nightly tenants meetings and one of the tenants is a representative at the Tenants Forum run by the organisation. During the visit to the Home staff were seen to make time to talk to tenants on a one to one basis. The pre inspection questionnaire states that there have not been any complaints made to the Home. The Commission has not received any complaints since the last Inspection. The relatives comment card states that they have not made any complaints but also states that they are not aware of the complaints procedure. It is recommended that the Manager ensure that all relatives are aware of this procedure. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 16 All staff receive training with regard to Safeguarding Adults (Protection of Vulnerable Adults) and staff who spoke to the Inspector were clear about their responsibilities to report concerns. The aims of the policies and procedures of the Home are to protect the tenants from any form of abuse. All of the completed tenants comment cards state that they feel safe at the Home. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home is comfortable, homely and meets the needs of the tenants. EVIDENCE: The Inspector saw the communal rooms on the ground floor, the bathroom and toilet on the first floor and one of the tenants showed the Inspector their bedroom on the first floor. The tenants now use the larger main lounge on a regular basis with the smaller room being used mainly when tenants want to have a more confidential chat or by staff and tenants when completing paperwork. The front lounge has new furniture and is a warm and welcoming room. The Home has a separate dining room as well. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 18 The bathroom and toilet on the first floor have been refurbished and are attractive and homely looking. The tenants room is large and bright. The tenant has decorated and furnished it to their own taste and there are lots of photographs, ornaments and other personal items around the room. The majority of tenants have keys to their rooms. Several of the tenants comment cards state that their bedrooms are one of the good things about the Home. The Home was clean and free from offensive odours on the day of the visit. The Home has recently become a non smoking Home and a structure has been built outside so that the tenants who smoke are able to smoke there in poor weather. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 19 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, 33, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Adequate staffing is provided to support the tenants Staff receive good induction and training Staff have a good understanding of the tenants needs Effective recruitment procedures are followed Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 20 EVIDENCE: The rotas show that there is always at least two members of staff on duty throughout the day. On occasions, depending on the needs of the tenants, there may be a third person on duty. The times that staff start work in the afternoon means that there are often four members of staff on duty for a period of between one and three hours during the early part of the afternoon. There is a member of staff sleeping in at night. Staff and tenants said that there are always enough staff on duty to enable tenants to access their planned activities and also the more informal activities that they may choose to do at weekends. Tenants said that if they want to stay at home rather than go out they can do so. The tenants comment cards all state that they feel well cared for and that the staff treat them well and listen to them. Staff were observed to communicate well with the tenants and there was a lot of interaction between staff and tenants. Staff who spoke to the Inspector said that they receive good induction and ongoing training which is relevant to their role. They said that they enjoy the training and that they are able to have the time to attend the courses. Records show that all staff have attended mandatory training and that dates are booked for the coming year for any that require updates. As well as mandatory training courses in other, relevant, subjects are also provided. The pre inspection questionnaire states that 50 of staff have completed NVQ Level 2. Staff records confirm their attendance at a range of courses. The records also show that appropriate recruitment procedures are followed, including relevant checks on staffs identity and previous experience. Staff said that they enjoy working at the Home and appear to be enthusiastic about supporting the tenants. They have a good understanding of the care plans and of the individual needs of the tenants. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 21 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 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home is well managed and the tenants receive good support from the Manager and the deputy manager. The views of the tenants underpin the development of the service The health and safety of the tenants and staff is given a high priority Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Manager has many years experience of managing a Home within this organisation. She moved from another Home within the organisation approximately a year ago. The Manager has also recently taken on additional management responsibilities within the organisation but staff and tenants said that she still spends time in this Home. The Home also has a deputy manager who works full time in the Home and who has many years experience of working in this Home.. She provides a lot of the day to day management support to staff and tenants. The managements tasks appear to be divided between the Manager and the deputy manager. The staff and tenants spoke highly of the Manager and deputy and the open management style that they have. As previously mentioned within this report the Home has a variety of ways in which the quality of the service is regularly monitored. This also includes questionnaires that are sent to relatives and health professionals and an annual development plan. These all now need to be brought together into an annual quality assurance report. A requirement is made about this. The health and safety of the tenants and staff is given a high priority. Staff receive training with regard to Health and Safety, Emergency Aid, Fire Safety and Food Hygiene. Monthly health and safety checks are carried out with records of action taken to address any issues. A fire risk assessment has been carried out and records show that regular servicing takes place of the fire safety equipment. Mandela House DS0000027484.V330071.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 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 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 3 33 3 34 3 35 3 36 X 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 3 X 3 X X 3 X Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 24 no 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 YA39 Regulation 24 Requirement It is required that an annual quality assurance report is produced and that a copy is sent to the Commission Timescale for action 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 YA22 Good Practice Recommendations It is recommended that the manager ensures that all relatives have a copy of the complaints procedure. Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Mandela House DS0000027484.V330071.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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