Inspection on 20/11/06 for Mandeville House

This inspection was carried out on 20th November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mandeville House 14/10/08

Mandeville House 23/10/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Mandeville House 35 Larches Road Kidderminster Worcestershire DY11 7AB Lead Inspector Martha Nethaway Unannounced Inspection 20th November 2006 11:30 Mandeville House DS0000067880.V317601.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 Mandeville House DS0000067880.V317601.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. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandeville House Address 35 Larches Road Kidderminster Worcestershire DY11 7AB 01562 752271 01562 752271 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) Minster Pathways Limited Mr Donald Alex Forbes George Care Home 7 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (3) of places Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate service users who have an additional mild physical disability. The number of service users will be reduced to 6 when a vacancy in the home occurs with the existing undersized bedroom having single occupancy. Date of last inspection Brief Description of the Service: Mandeville House is situated in a quiet, residential area of Kidderminster, close to a wide range of amenities. The home is a large, detached property registered to provide residential i.e. personal, long-term care to a maximum of seven adults with learning disabilities. The current service users have mild/moderate learning disabilities. All of the service users are male and all of them have been resident in the home for a number of years. The service users are accommodated on the ground and first floor of the premises in five single bedrooms and one double bedroom. None of the bedrooms have an en suite facility. The home does not provide a passenger lift or a stair lift. However, none of the service users have a physical disability and all are fully ambulant. There is limited car parking space at the front of the premises and a large garden at the rear. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit-taking place over five hours. One inspector visited to observe the midday and daylong schedule for service users. Most of service users were met and two service users provided a guided tour of the premises. Discussions were held with the registered manager. A random selection of records were examined. What the service does well: What has improved since the last inspection? What they could do better: • The arrangement for fees and any on costs for placements need to be recorded in the home’s literature. This will ensure the home is complying with new regulations. Ensure all records are signed and dated. This will demonstrate accurate records are being maintained. Consider implementing the ‘health action record’ as recommended by the local PCT. This will provide comprehensive evidence of good health care planning. All care staff should be provided with accredited medication training. This will increase staff knowledge. The risk assessments tool needs to be thorough and this will indicate a good practice approach to risk management. The new provider should continue to make improvements and refurbishment to the property. This will upgrade the property. • • • • Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 6 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. Mandeville House DS0000067880.V317601.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 Mandeville House DS0000067880.V317601.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): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good structures are in place for assessment. The provider will need to revise service user’s literature to reflect transparency of fees and any additional on costs for placements. EVIDENCE: The new provider is in the process of implementing the corporate ‘assessment of needs’ policy, guidance and procedure. The provider would be expected to consult relatives, social workers and other care professionals when undertaking the assessment. One file was examined and the registered manager had completed a ‘Basic Practical Independence Assessment’ tool, that just needed to be dated. All of the service users living at the home have been accommodated over a lengthy time span, in some cases over 20 years. Relatives are able to retain involvement and interest where it is determined to be appropriate. None of the service users are self-funding. The provider is reminded to amend existing guidance and literature to reflect the recent changes with legislation. This includes improved transparency about fees and any additional costs for Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 9 services. Risk assessments are in place but the process of review needs to be improved and this will be referred to under standard 9. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning is considered but the new provider intends to adopt ‘Person Centre Planning’ to enable service users to reach for the best outcomes. The risk management tools needs to be comprehensive and staff training should be in parallel with this. Good processes are in place for the management of service user’s financial arrangements. This should also be referred to in the statement of purpose for the home and similarly the service user’s guidebook. EVIDENCE: As stated in the previous inspection visit, the care-planning process met most of the elements expected to be in place for a care plan document. It details how their independence will be promoted. Further refinement was recommended at the last inspection visit. This correlated with describing what Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 11 specific action staff needed to take in response to meeting the needs of service users. In response to this, the new provider is to adopt a ‘Person Centred Plan’ and this will contribute to progress being reviewed and the best outcomes for individuals being worked towards. It was considered too early to assess this process, as the new provider has only taken over the home in the past six weeks. It is anticipated it will be operational at the next inspection cycle. There was good indication that this would be achievable, as staff were recording detailed information about the level of day-to-day interactions. What had been made available and when staff input had been turned down by service users. Service users were in the process of being consulted about the individual care plans as part of the person centred planning approach. The new provider continues to operate a keyworker system with a designated staff member allocated to each individual. One parent provided positive feedback about the professional relationship maintained with his son. None of the service users had involvement with local advocacy services. It is recommended that the registered manager should ensure that information and leaflets are freely available to both service users and their relatives should this need arise. Likewise, information is also available on advocacy via the British Institute of Learning Disabilities and this should be published in the home. There is a formal process to review service user’s needs and individuals are encouraged to attend their review meetings. One meeting had been arranged with the local authority and the overall feedback was positive. The home has procedures in place for managing and controlling financial matters for individual service users. These include a simple petty cash process to monitor expenditure and these accounts are monitored weekly and formally reconciled monthly and forwarded to head office. Each service user holds a personal bank account. It is recommended that the registered provider should refer to the arrangements for managing personal finances in the statement of purpose and service user’s guide. Relatives, social workers and independent advocates may have a role in ensuring these arrangements suit the best interests and wishes of the account holder. The monthly regulation 26 visitor randomly samples the homes and service user’s financial records. This is in response to the recommendation set at the last inspection visit, which is now met. Risk assessments are available but do not meet with the expected levels of risk management or have the complementary staff protocols detailing how risks will be minimised. This whole area was discussed with the registered manager and he anticipates that new risk assessments will be completed by December 2006. It is recommended that staff receive training related to a risk management overview. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables service users to attend day service provision and access the local community resources. Contact with relatives is actively encouraged. The keyworker role is well defined and promotes service user’s interests. Meal times are well organised and a varied diet is endorsed. Consideration should be given to incorporating good practice models related to food and nutrition. EVIDENCE: The home has an organised approach to providing structured points to the day for service users. Information about planned activity events was prominently displayed in the staff office. Service users are accessing Kidderminster College and attending adult education courses. These include creative movement, music and craft. Three service users are accessing the Meadows Access Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 13 Centre and four service users attend Odell Resource Centre. Three service users also access the Youth House and attend sessions in pottery and music. One service user has his own activity planner and is not affiliated with any social or education facility. The new provider is considering approaching Chester Road day service to assess if this is would be considered an appropriate provision. The home would be expected to provide staffing input and supervision. Staff are employed from the local area and are considered knowledgeable about the provision of local services and events taking place in the community. Service users are encouraged to independently use the local shop and local pub and service users spoken to confirmed this. These are within walking distance of the home. All of the service users are registered to vote. The registered manager and staff consider the service group are able to effectively communicate their needs and share their views and options. There is no one accommodated at the home with a different cultural, racial or ethnic background. The provider acknowledged that further training was needed to raise staff awareness and intends to access training related to equality and diversity. The provider will monitor who is employed by the home in relation to its commitment to employment, training and promotion. Service users are able to maintain links with their relatives. Some service users stay for overnight stays with their parent/s or carers and visitors are regularly recorded in the visitors book over the weekends. The house can accommodate visitors without interrupting existing service users. The registered manager considers that good relationships are formed with families and staff make relatives feel welcome. The registered manager is planning to send out questionnaires to ascertain their views of the home and if any areas could be improved upon. Questionnaires have been sent out to the local GP and Nurse and it was reported that the feedback was positive. Keyworkers encourage service users to take responsibility for cleaning their bedroom and in practical ways support this. The registered manager was open and honest and expressed his view that some service users were keen to be involved in domestic tasks around the home, others are not and this will be recorded with their agreement in their person centred plan in the future. As identified at the last inspection visit, there has been no change with the status of the meals including the quality of food provision, preparation and timing of meals. Menus are available. It is recommended that the registered manager refer to the latest CSCI report on meals in care homes. Similarly, the provider should refer to the National Institute for Clinical Excellence (NICE) guidance on nutrition for adults who provide guidance and advice on good practice models relating to nutrition. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provider is considering the health and wellbeing of service users. Health care planning could be further improved by adopting the good practice model of a ‘Health Action Plan’ record, implemented by the local PCT team. The provider should supply accredited training that equips staff to carry out the task of administrating medication competently. The provider needs to address how ageing and illness will be planned for in the future. EVIDENCE: Service users in most cases are able to manage their own personalised care. Staff are able to provide verbal direction and advice. The new provider will be implementing an ‘intimate care policy’. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 15 The care plan at present indicates that service users prefer day-to-day routines. These are not highly detailed. Once the Personal Care Plans (PCPs) have been implemented this will provide a more thorough plan of care and provide clear evidence of where the individual areas of strength and self-management are. The case records connected to service users provided evidence of appointments being made with GPs, dentists and other health care professionals and gave a narrative account of these appointments. It is recommended that the home should consider adopting the local PCT ‘Health Action Record’ for adults with a learning disability. This is a user-friendly booklet providing details associated with health care needs. The registered manager should establish contact and attend the necessary facilitator training to implement and adopt this manual. This will provide a comprehensive document to address all matters related to health needs and promotion. The arrangements for chiropodist/podiatrist will also need to be referred to in the health check manual. It is recommended that the home provide clear care practice guidelines about how nail care will be managed at the home. The Commission’s website provides some useful reference points to consider. The new provider needs to implement the previous recommendation related to supplying suitable accredited training in the administration of medication. Skills for Care have recently published a ‘Knowledge and Skills Set’ related to Medication. Details are available on the Commissions website. It is recommended that the provider ensure that staff understand the underlying principles of the home’s policies and procedures for drug administration and the importance of good practice. The new provider will also need to address standard 21 and the outcome linked to ageing, illness and death of a service user so that these are handled with respect, as the individual would wish. This recommendation made previously is being repeated. Service user’s records should include greater detail about the arrangements for terminal illness and following death e.g. whether the service user wishes to be buried or cremated and where. The type of service including favourite hymns and readings (if any) etc. The provider should establish contact with the local speech and language therapist who can supply useful tools related to discussing how to make a will. Staff should also be supplied with training related to life span, ageing and illness. The new provider shows the capacity to be able to address these areas in a careful and considered manner. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides policies that promote protection and safeguard service users from abuse. There are processes in place to respond to vulnerable adult concerns. The home provides information about how to complain. EVIDENCE: The home has a policy available related to the protection of vulnerable adults and a copy of the ‘Reporting abuse or mistreatment of vulnerable adultsguidance for staff’ produced by the Worcestershire Vulnerable Adults Protection Committee. A whistle blowing policy complements this document. It is recommended that the provider should have available the ‘No secrets’ guidance for staff to refer to. Currently there are no live issues related to adult protection. It is recommended that the registered manager should attend training related to POVA procedures organised by Worcestershire county council. The home needs to introduce a hardback bound book to record all allegations and incidents of abuse and any action taken. This was discussed with the registered manager at the time of the inspection visit. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 17 The home has available guidance about how service user’s monies will be managed and recorded. The process discussed earlier in this report indicate good financial record keeping. The records linked to complaints were examined. No complaints have been received and contact details are available for the provider and the Commission in the homes literature. The provider needs to introduce a hardbound book to record complaints as specific under standard 22.7. This was discussed with the registered manager at the time of the visit. The provider should contact the local authority about changes to the adult social service complaints procedures, which came into force in September 2006. This will need to be signposted in the providers own complaints procedure. The registered manager cited an ‘open door’ policy for service users and staff employed at the home. Should anyone wish to question the care provision or the practices of a staff group. There is also an accessible process for relatives to raise concerns during the annual review process and at the point of quality questionnaires. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 & 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 kept satisfactorily and the provider has the ability to improve décor of the home. The provider should adopt local guidelines related to managing health infection control. EVIDENCE: The home is a detached property set in a central location in Kidderminster with good access to local transport facilities. The new provider was in the process of replacing a bathroom suite during the inspection visit. A skip was being used to dispose of unwanted items stored elsewhere around the house. The home is being adequately maintained. The new provider is consulting with service users with regards to decorating communal and bedroom areas. It is anticipated this will take about six months to complete. The previous recommendation is being repeated in connection to obtaining a copy of the ‘Guidelines for Infection Control in Care Homes’ dated 2003 produced by Herefordshire and Worcestershire Local Health Protection Unit. Mandeville House DS0000067880.V317601.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): Standard 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider has not yet achieved the expected number of levels of qualified staff employed at the home. Training and development needs of the staff needs consideration for the future. A training and development plan should be implemented that pays attention to the stated aims and objectives of the home. Recruitment and selection is complying with the home’s own operational procedures. EVIDENCE: The home employs a total of eight staff working a shift rota pattern. Two staff are expected to be available to cover each shift. The staff team is supplemented with permanent relief bank staff. The experience and skill mix of the team is varied. The registered manager described the team as approachable and was confident with their input to provide support and care. Promotion of independence was cited as a key expectation of staff interactions. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 20 The manager ensures that he has opportunities to observe team members’ practices. Consideration should be given to auditing the skills and experience necessary for the task identified under standard 32.3. Three staff hold a NVQ level 2 in Care qualification. The provider has not yet met the expected level of 50 of care staff being qualified. The recruitment of staff was examined. There was evidence of the necessary employment checks being carried out. This included an application form being completed and dated, two references, a statement of terms and conditions and a job description. The registered manager is aware he should make verbal contact to verify and validate the content of at least one of the references given. A full written record is retained on the file as evidence. The files checked showed evidence of CRB checks being completed and were up to date. All new employees are subject to a probationary period and induction processes. It is recommended that evidence should be available on the personal file of staff receiving copies of the code of conduct and practice set by the General Social Care Council. It is also recommended that CRB checks should be repeated at three yearly intervals in line with good practice measures. The registered manager stated that supervision is taking place. The new provider has assessed the skill and training needs of the staff group. This enables a thorough understanding of future planning related to training and development for the staff group. Training related to basic food hygiene was identified as deficient. The provider is reminded that staff should have access to equal opportunities, disability and equality training. Particular attention should be given to the specific areas identified within standard 35.4. Training updates in most disciplines should occur every 2-3 years. The provider should consider the need to ensure that staff are trained to the Learning Disability Award Framework (LDAF). The Skills for Care induction and foundation standards were updated in October 2005. The provider should refer to the Commission’s website for further clarification of this area. Mandeville House DS0000067880.V317601.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): Standards 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs a suitably trained manager to run the home. He is considered approachable and professional. Good processes are in place to adhere to health and safety matters. The fire evacuation needs of individuals should be referred to in the service users case records. This will further promote fire safety awareness. The provider should have a clear response for any anticipated emergencies and contingency plans should be in place. The processes used to risk assess need appraising. Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Commission approved the registered manager in September 2006. He holds a NVQ4 Registered Managers Award. He has had relevant experience in the field of disability in children’s and adult’s services. The manager considers himself to be a ‘hands on manager’. He likes to work alongside the staff team and to be involved in the day-to-day events of the home. Time is set aside for the administrative duties related to the management of the home. The provider’s infrastructure permits a large part of the financial administration to be organised centrally. The registered manager should continue to undertake periodical training to maintain his professional knowledge basis. The provider is reassessing the outcomes related to self-monitoring. A new tool is being implemented to capture the assessment process and areas for improvement. As this has not been fully implemented it is too early to comment on quality assurance for the home. The registered manager did state that questionnaires had been circulated to all stakeholders and feedback is being analysed. During the inspection visit, evidence was supplied about how safe working practices are adopted. All of the domestic installation checks have been completed including gas and electrics. There was evidence of maintenance of the central heating system. Fire safety records were up to date and regular fire drill practices are taking place. It is recommended that the evacuation needs of individuals should be recorded in service user’s personal records. To complement this area the registered person should make sure staff know what these needs are and be trained to evacuate anyone who needs help. It is recommended that the provider have a clear response for the home to anticipate emergencies, such as power failures or flooding, and have contingency plans in place. Good practice would also be to involve people using the service in making such plans. As mentioned earlier, risk assessments were examined. The provider is compiling a thorough audit of risk assessments around the premises and this was available during the visit. The risk assessment associated with individuals needs to be more comprehensive with response to the review process and staff protocols to minimise hazards and reduce risks. Mandeville House DS0000067880.V317601.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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes, but new time scales have been set. 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 YA1 Regulation Requirement Timescale for action 28/02/07 2. YA6 3. YA9 4. YA22 5 The provider must amend (June,2006) service user’s literature to reflect transparency of fees and any additional on costs for placements. This will ensure that information is inline with recent changes to the National Minimum Standard Regulation 5 June 2006. 15 The service users plans must 28/02/07 set out in clear, specific detail and any the action that should be taken by the care staff to be recorded to ensure that all aspects of the service user’s needs are met. 13(4) Risk assessments must 28/02/07 thoroughly assess hazards and have the complementary staff protocols detailing how risks will be minimised. 22(8) The provider must introduce a 28/02/07 hardbound book to record complaints as specific under standard 22.7 headings. 13 The home must introduce a hardback bound book to record all allegations and incidents of abuse and any action taken as DS0000067880.V317601.R01.S.doc 5. YA23 28/02/07 Mandeville House Version 5.2 Page 25 detailed in standard 23.3. 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 YA2 YA7 YA7 Good Practice Recommendations All case records should be signed and dated. The processes in place for the management of individual’s financial arrangements should be referred, to in the statement of purpose and the service users guidebook. The registered manager should ensure information and leaflets are freely available to both service users and stakeholders about advocacy services. Likewise, information should be available on advocacy via the British Institute of Learning Disabilities and this should be published in the home. Service users level of involvement with domestic tasks around the home should be recorded with their agreement in their person centre plan in the future. The registered manager should refer to the latest CSCI report on meals in care homes. Similarly the provider should refer to the National Institute for Clinical Excellence (NICE) guidance on nutrition for adults who provide guidance and advice on a good practice model relating to nutrition. The home should adopt the local PCT ‘Health Action Record’ for adults with a learning disability. The registered manager should establish contact and attend the necessary facilitator training to implement and adopt this manual. The arrangements for chiropodist/podiatrist should be referred to in the health check record. The home should provide clear care practice guidelines about how nail care will be managed at the home. The Commission’s website provides some useful reference points to consider. 7. YA21 The wishes of all the service users concerning terminal DS0000067880.V317601.R01.S.doc Version 5.2 Page 26 4. YA16 5. YA17 6. YA18 Mandeville House 8. 9. 10. YA22 YA22 care and death, including religious customs, should be discussed and recorded in their individual files. The provider should have available the ‘No secrets’ guidance for staff to refer to. The registered manager should attend training related to the Protection of Vulnerable Adults organised by Worcestershire county council. A copy of the ‘Guidelines for Infection Control in Care Homes’ dated 2003 produced by Herefordshire and Worcestershire Local Health Protection Unit should be obtained and kept in the home. There should be evidence available on the personal file of staff receiving copies of the code of conduct and practice set by the General Social Care Council. It is recommended that CRB checks should be repeated at three yearly intervals in line with good practice measures. YA30 11. YA34 12 YA35 Staff should have access to equal opportunities, disability and equality training. Particular attention should be given to the specific areas identified within standard 35.4. Training updates in most disciplines should occur every 2-3 years. The provider should consider the need to ensure that staff are trained to the Learning Disability Award Framework (LDAF). 13 14. YA37 YA42 The registered manager should continue to undertake periodical training to maintain his professional knowledge basis. The evacuation needs of individuals should be recorded in service user’s personal records. To complement this area the registered person should make sure staff know what these needs are and be trained to evacuate anyone who needs help. The provider should have a clear response for the home to anticipate emergencies, such as power failures or flooding, and have contingency plans in place. Good practice would also be to involve people using the service in making such plans. 15. YA42 Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Mandeville House DS0000067880.V317601.R01.S.doc Version 5.2 Page 28 - 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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