Inspection on 23/10/07 for Mandeville House

This inspection was carried out on 23rd October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 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 20/11/06

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 Rachel McGorman Draft – Key Unannounced Inspection 23rd October 2007 09:00 Mandeville House DS0000067880.V346642.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.V346642.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.V346642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandeville House Address 35 Larches Road Kidderminster Worcestershire DY11 7AB 01562 752277 01562 752277 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 ****Post Vacant**** 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.V346642.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. 20th November 2006 Date of last inspection Brief Description of the Service: Mandeville House is registered to provide personal care for up to seven people who have a learning disability, which may include challenging behaviour, and who may have an additional physical disability. The resident group are all male and have lived together at the home for several years. The house is a large detached property, situated in a quiet, residential area, approximately one mile from Kidderminster town centre. There is access to public transport and a range of amenities and facilities. The home also has a minibus, for the benefit of the people who live at the home. The home had been under the same management for many years, and was purchased in 2006 by Minster Pathways Ltd.. Mr Colin Farebrother is the Responsible Individual. Support to staff working at the home is provided by Mrs Maria Baughurst, the Operations Manager, and Ms Jacqui Matthews, the Area Manager. The acting manager is Ms Haley Martin, who also has responsibility for The Brintons, another home in the group and which is located approximately half a mile from Mandeville House. The weekly fees range from £297- £596. The stated aim of the home is to foster an atmosphere of care and support, which enables residents to live a full and interesting, and as independent a lifestyle as possible, where positive choice and personal development are encouraged, and to also help each person to achieve their potential. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. Preparation for the inspection included looking at previous reports, considering the various contacts made with the home since the last inspection, and making arrangements for surveys of relatives and staff to be circulated. The visit was unannounced and took a total of 4 hours. The inspector spent some time with the people who live at the home, finding out what it is like to live there, although some are not easily able to communicate their views verbally. Observation of the interactions of the residents with the people who support them was very positive, and the relationship between them was seen to be respectful and considerate. During conversations with staff, comments were made about what it is like to work for the company, how the home is organised and how they support the people who live at Mandeville House. In addition the opportunities for training and the supervision they are given in doing their work was also discussed. The care records of service users were seen, and discussion about the content held with the acting manager, who was on duty throughout the inspections. The care plan of one resident was inspected in detail for case tracking purposes. The inspector was also able to meet with the responsible individual, Mr Colin Farebrother to discuss proposals for future management arrangements at the home, and also the ways in which the organisation is intending to develop the service. A tour of the house was undertaken, and the records kept in respect of the maintenance of equipment, and safe working practices were also seen, including the fire log and the accident book. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 6 What the service does well: Mandeville House is a friendly home, and a warm welcome is given to visitors, including the inspector. There is evidence of mutual respect and consideration between the people who live at the home and the staff. The atmosphere throughout was calm and relaxed, although residents were quite ‘busy’, and several people were getting ready to go out in the minibus. The procedures relating to the assessment and admission of people who may want to live at the home are in place, to ensure that the needs of prospective residents are identified, and to enable staff to determine if they can be cared for appropriately at the home. Residents are encouraged to make more decisions about their lives, both within the home and also outside in the community. Opportunities for each person to do the things they enjoy are increasing, and as a result their life skills and confidence are also developing. A good standard of personal and health care is provided for residents at the home, and the staff work well with other professionals and agencies, to help improve and maintain the health of the people who they support, with obvious benefit to everyone. The policies and procedures relating to the administration of medication and the training provided for staff help to ensure that residents are protected. Recruitment and selection procedures are followed, and the management is clear about the support, training and development for the staff it employs. Staff confirmed that they are given regular supervision and appropriate training opportunities. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? A Statement of Purpose has been produced, and can be made available in a suitable format when required. Relevant information is available about the services and facilities that can be provided at the home, to assist prospective residents and their families to make the right decisions about their care. The Service Users Guide is being reviewed at present, and the updated version will be available in the near future, to give additional information about the home. Care planning procedures have been reviewed, and the Person Centred Planning approach is being introduced, which should improve the quality of life of each resident. There is an ongoing commitment from the management of the home, to the further development of the service, and to putting the people who live at the home at the centre of everything. Progress in accessing more activities for residents in the local community was evident, and these opportunities should help to increase their enjoyment of life. The home has a vehicle to provide transport for residents, to enable them to undertake various activities in the community. The arrangements for food give everyone a choice about their meals and mealtimes, provide them with the opportunity to help with the shopping and also preparing the food, and having more involvement in the running of the home. The complaints procedure is now produced in a format that is understandable to residents, and this includes pictures, and it is circulated to everyone involved with the home, to enable them to voice any concerns. The policy and procedures on the Protection of Vulnerable Adults (PoVA) have been reviewed and updated, to include the procedure to be followed in relation to staff who may be unsuitable to work with vulnerable people, and a copy of the Department of Health guidance, ‘No Secrets’, is now available. Facilities have been improved for the people who live and work at the home by further development and of the premises, specifically, the replacement of some of the furnishings and various items of furniture, and also the purchase of several new items of equipment. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 8 What they could do better: The information available about the home and the services that can be provided has been reviewed, although will need to be amended further to reflect the new management arrangements for the home in due course. The ongoing development of admission and assessment procedures to enable staff to know if they can provide appropriate care, and the introduction of a more person centred approach to care will improve the quality of life of the people who live at the home. The various activities are now supported by risk assessment, to promote the safety of residents and enable them to have more independence, although the need for further development was identified, and each resident should be also given the option of having an annual holiday. The use of advocacy services for a resident without any immediate family should be considered, to ensure that any decisions that need to made are in the best interests of the resident. Consideration should be given to the wishes of each resident in regard to after death arrangements, to enable this to be dealt with sensitively and with respect, and staff should be trained to ensure they understand the issues relating to death and bereavement. A record should be maintained of all the comments or compliments made about the home, which will help to give a balanced view of the service that is being provided for residents. Further work should be undertaken to the areas of the house and garden that need attention, to improve the facilities that are available for residents and to ensure that appropriate standards are maintained for the people who live and work in the home. A review of the premises should be undertaken, and risk assessments completed, which should be followed by appropriate action in respect of the guarding of radiators and fitting of window restrictors, for the safety and protection of the people who live at the home. The further development of the quality assurance system, to include the auditing and publishing of the results of the surveys and questionnaires, will help ensure the best possible outcomes for the people who live at the home. A contingency plan to ensure the protection of residents in the event of the occurrence of an emergency situation remains outstanding. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 9 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.V346642.R01.S.doc Version 5.2 Page 10 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.V346642.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information provided for people who are considering moving to the home, will help them to make the right decision about their future care arrangements, although further review of all the documentation will assist this process. The pre-admission assessment procedures are detailed and thorough to ensure that the home is able to provide the appropriate care, although a Community Care Assessment will help the right decision to be made. The admission procedure includes planned visits to the home to meet other residents and the staff, and this helps everyone to know if the home will be suitable for them. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 12 EVIDENCE: A Statement of Purpose and a Service Users Guide have been produced, and can be made available in a suitable format when required. A copy of the Statement of Purpose was seen, and this document had been reviewed and updated recently, but will need further amendment to reflect the management arrangements when a new manager is appointed. Relevant and detailed information is included for residents and their families, about the services and facilities that can be provided at the home. The acting manager confirmed that the Service Users Guide is also being reviewed, and the updated version will be produced specifically for the resident, and will also contain pictures to enable a clearer understanding. Information will be included about the contract and also about how to make a complaint. In addition a brochure is to be produced, that will provide more information, to assist people to decide if the home can meet their needs. Discussions about how the admission of a new resident to the home would be achieved, were held with the acting manager, who confirmed that an initial assessment is undertaken by the manager, usually in the prospective residents own home, and several visits to Mandeville House are then arranged, together with the family, if appropriate. This process, which is detailed and thorough, will enable people who may wish to move to the home, to make the right decision about their future care, and also help staff to know if they can meet their specific needs. There have been no recent admissions to the home, although the file of one resident was inspected in detail as part of the case tracking process. There was an assessment in place, which had been undertaken by staff from the home, but there was no Community Care Assessment provided by a social worker from the placing authority. The initial assessment is used as the basis for the plan of care that is developed for each resident. The acting manager confirmed that for future admissions that are funded by the Local Authority, the service would ensure that a Community Care Assessment is obtained prior to admission. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The plan of care is based on the initial assessment, which clearly identifies the assessed needs of each resident, and how these will be met, and the ongoing development of the person centred approach to care will help to ensure that all the decisions made revolve round the people who live at the home. The key-worker system ensures that residents are supported in making choices in all areas of their lives, and further development of the risk assessment process will ensure a responsible approach to the risks associated with the various activities of daily living. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 14 EVIDENCE: Care planning procedures have been further developed at the home, and those seen detail the needs of each person and how these are to be met. An individual plan of care is produced for each resident, which is based on the initial assessment undertaken at the time of admission. The content of the plan is reviewed regularly, with the resident, to ensure that it accurately reflects the care that is provided. The acting manager confirmed that progress has been made, but that further development is needed to ensure that each care plan is a true reflection of the wishes and aspirations of each resident and contains all the relevant information to enable person centred care to be delivered. The care plan viewed during the visit was informative, gave a clear profile of the resident, and increasingly shows that life at the home revolves around the people who live there. Observation of the relationship between the staff and the people they support, and talking with residents, also provided good evidence of the person centred approach that is being taken at the home. The plan of care covers all aspects of the needs of the resident, changes are monitored over a period of time, and amendments made when necessary. A pen picture of the individual is included, together with details about contacts, personal and health care, and ‘keeping track’, which covers arrangements for meals, housework, shopping, clothes, activities and outings. Staff explained the routines of the people they support, and their care needs. Two key-workers are assigned to each resident, and staff showed that they understand their role in ensuring that appropriate care is provided. The inspector was told that the placements of some people living at the home have been reviewed by Social Services, but others have yet to be undertaken. Several residents who were spoken to during the visit were obviously very settled and content with life at Mandeville House. One service user said, ‘he was very happy at his home’, and another person was quite positive about the home, saying, ‘things are alright here, and I’m quite happy’. One resident said he ‘liked going out’, and that, ‘they go out all over the place in the van’. A gentleman who had lived at the home for a long time, and was very talented with his hands, proudly showed me some of the lovely pottery pieces that he had produced at a day service that he attends. Risk assessments are completed, in relation to the premises, to the activities undertaken and any restrictions imposed, and also in regard to all aspects of the life of each person. The details are fairly well documented, and are reviewed regularly to reflect any changes, although the acting manager confirmed that she had been working with staff to develop them further. Guidelines have been produced to provide staff with a better understanding. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The involvement of each individual in planning their activities, both within and outside the home, means that they can choose what they wish to do. The opportunities made available to residents, and their regular contact with family and friends, enable them to live a full and interesting life, although advocacy services also need to be involved to ensure that the interests of all residents are protected. There is a flexible approach to the provision of a healthy diet, and each person is encouraged to decide what to eat and when. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 16 EVIDENCE: Residents living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a range of activities. There has been some progress in accessing activities within the local community, although these opportunities are being further explored, for those who wish, to increase their enjoyment of life. An individual programme of activities is arranged with each resident that acknowledges their preferences, and the daily routines revolve around their personal choice. The wishes of every individual are respected and recorded. If they decide they don’t want to do something or to go somewhere, then they don’t have to. Evidence was noted in the care plan of one person who did not want to continue attending the College after trying it for a while. A record is maintained about what each individual has achieved that day, and confirms the various day placements that are attended. A weekly planner is also being introduced to record the proposed activities for each person. One resident is able to access the local shop, which is a regular part of his routine, and he also goes into town for a coffee and to do some shopping. Another person who used to be more independent, but had lost those skills, is being reintroduced to doing things independently again, although he is still ‘shadowed’ by staff at present. One person who usually prefers to be on his own, will occasionally join the group, and go out for a ride in the minibus. He also likes to help around the house, and will lay the table for meals and clear away the dishes afterwards. Everyone is now being encouraged to make snacks and drinks, and staff support individuals to achieve their specific goals, and this includes developing and maintaining their life skills, by doing general household chores. One resident particularly enjoys doing the hoovering. Most residents enjoy music and have their own players, or will watch TV or a video with the others. Group activities are also organised, and visits to places of interest have included Cadbury’s World, a butterfly park, West Midlands Safari Park and Weston-Super-Mare. Future proposals are to go to the Sea Life Centre, the Walsall illuminations and Blackpool. Holidays were not organised this year, but the acting manager confirmed that plans are already underway for next year. Trips to the cinema and to a local disco are also organised, and other activities include baking, gardening, going for a picnic or a walk in the local park, or on a shopping spree, and going to a pub for a meal or a drink. Birthdays are also celebrated at the home, together with the families and friends. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 17 The home has a vehicle for transporting residents to their placements, going to places of interest, or visiting family and friends. Involvement with the local community and also with the relatives and friends of the people who live at the home, is actively encouraged, and everyone has regular contact with their family, with one exception. The issues with regard to the resident without any immediate family were discussed with the acting manager, and arrangements for the involvement of advocacy services, to ensure that appropriate decisions are made in the best interests of the resident will be implemented without delay. The arrangements regarding the provision of food reflect the individual likes and dislikes of each resident, and everyone is encouraged to help to prepare a menu for that week, although there may also be a spontaneous response to a suggestion to go out for a meal or have a ‘take-away’. These changes and individual preferences are recorded. Everyone is encouraged to be involved in food shopping with staff, and they also assist with the preparation. Healthy eating is promoted for everyone, and a record is kept of the food provided. Following a visit from the Environmental Health Officer, the home has implemented the ‘Safer Food, Better Business’ system, produced by the Food Standards Agency, which was developed to help compliance with the regulations relating to food management. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 & 21 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manner in which support is provided by staff helps to ensure that the rights of each resident are respected, when meeting their personal and health care needs. The procedures for the administration of medication ensure that the health of each resident is promoted, and that they are protected. Training is to be provided for staff to ensure a greater understanding of the issues regarding death and bereavement, and to enable them to deal with residents and their family more appropriately. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 19 EVIDENCE: The personal and healthcare needs of each resident are well documented. Discussion with the manager and staff showed how they understand and are able to respond to the needs of residents in an appropriate way. One person was able to discuss how this worked for him, and confirmed that his personal care is provided in privacy, and that he is given help by staff only if needed. The acting manager confirmed that residents do not need much assistance with their personal care, as they are all fairly independent, and only need to be reminded or prompted from time to time with general hygiene matters. Reviews are undertaken regularly with each individual to ensure that any changes are responded to appropriately, and these are also recorded. The independence and dignity of each individual is promoted, and a relaxed and flexible approach maintained when providing personal care. The healthcare of the people who live at the home is closely monitored, and a health assessment is done for everyone, which is regularly updated. The consent of each person is obtained, and that of their family or representative, to record their health related information and to also pass this on to the relevant people when necessary. The plan of one resident was viewed and the information on the medical history of that person was evident in the records, and confirmed that appropriate care is provided. The acting manager explained that the weight of each person was being monitored closely, as some concerns about the low body weight of several people had been identified previously, and the matter discussed with the doctor. This situation is now resolved. Health Action Plans have not been introduced for residents living at the home, although some information from the Worcestershire HAP format has been included in the Health Monitoring Record of each resident, which are also produced in picture format. These contain information on general health issues, and also any specific treatments needed, together with visits to the doctor or consultant, the involvement of nurses, attendance at clinics, sight, hearing, dental checks, and chiropody treatment are all recorded, which helps to ensure that appropriate care is provided. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 20 Medication arrangements at the home are satisfactory, and residents are protected by the policies and procedures that are in place. Information about medication is also provided for residents in picture format, to aid their understanding. A Monitored Dosage System is in use, and the local Pharmacist undertakes a regular check to ensure that the correct procedures are being followed. The Medication Administration Records were seen and had been completed to a good standard, and training has also been provided for staff. Regular reviews of the medication prescribed for residents at the home are undertaken. A policy and procedure relating to death and dying has been produced at the home, and the wishes of residents regarding terminal care and after death arrangements are discussed with them, and their family or a representative, when appropriate, and a record is maintained in the plan of care. The acting manager discussed concerns regarding a resident at the home who is without any family, and whose arrangements in the event of death have not been planned. The acting manager agreed that the situation would be addressed without further delay, and appropriate action taken to resolve the matter. Training for staff on death and bereavement will be organised in the near future, to increase their understanding, and enable them to more effectively provide support for residents and their family. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and their family or a representative are able to express any concerns, through a clear and effective complaints procedure, although a record of all comments and compliments made about the home should also be recorded to ensure a balanced view of the service. The awareness of the management, together with the training provided for staff, ensures as far as possible the protection of the people who live at the home, from all forms of abuse. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 22 EVIDENCE: A procedure for the investigation of complaints has been produced, which enables people to voice their opinions, and any concerns are responded to immediately, the acting manager said, to prevent them developing into a larger problem. The document has been reviewed recently and is produced in a format that is clear to residents. Discussions about the procedure have been held with the families of the people who live at the home to make sure they understand the process, and they have also been given a copy. The acting manager confirmed that there have been no complaints about the service since the previous inspection, but a matter is being investigated under the Worcestershire Safeguarding Procedures in relation to a member of staff previously employed at the home. The allegations referred to financial irregularities that are being followed up by the police, although no residents have been directly affected by the situation. The acting manager reported that there have been many positive comments made by visitors to the home, relatives of the residents and professionals, about the attitude of staff, and the progress that has been seen in the recent developments at the home, although these have not been recorded. The acting manager was advised to maintain a record of all the comments and compliments made about the home, in order to provide a more balanced view of the service. A procedure is in place in relation to the many aspects of abuse and the protection of vulnerable adults, and all staff receive training as part of their induction process. Discussions with staff showed they have an awareness of these issues, and also an understanding of their individual role as an advocate for the people they support. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 23 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): 24,25,28 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a pleasant environment that is clean and comfortable, and that ensures as far as possible their safety and wellbeing, although this needs to be constantly monitored. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of each individual, with the exception of one undersize bedroom. The programme of improvement and upgrading of the home is helping to enhance the quality of life for the residents who live there, although not all the work has yet been completed. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mandeville House is a large detached property, situated in a quiet, residential area, approximately one mile from Kidderminster town centre. The home is within easy walking distance of several local amenities, and there is access to public transport, although the home also provides a vehicle for the use of residents when needed. There is a raised flowerbed at the front of the property and limited car parking facilities are available. The communal areas of the house include a kitchen, dining area and lounge. The lounge is nicely decorated and suitably furnished, in keeping with the modern, minimalistic approach, although some of the furniture is looking rather shabby and should therefore be replaced, which would improve the environment for the people who live at the home. The large garden to the rear of the property is accessed across a patio and down several steps, and these can be negotiated with care, but they are beginning to crumble, and therefore require attention to ensure the safety of residents. The gardens therefore are not easily accessible at present, and only for residents without physical disability. A brick built Bar-B-Que is the only feature in the garden at present, and it is very popular during the summer months, the inspector was told. The extensive gardens would be considerably improved with the addition of a greenhouse, for example, that would enable residents to grow tomatoes, and other items, and also a kitchen garden, for growing vegetables and fruit would benefit everyone living at the home. In addition garden furniture would further improve this facility for residents. The matter was discussed with the acting manager, who agreed to give consideration to the various possibilities, and to hold discussions with the people who live at the home and also the management, with a view to making better use of the area. There are five single bedrooms and one shared room within the home. Two single bedrooms are located on the ground floor and the other four rooms are on the first floor, but there are no en suite facilities provided. Agreement was reached at registration that the number of residents will be reduced to six when a vacancy occurs, as the existing shared bedroom does not meet the minimum standard in respect of space requirements. The need for upgrading of the property was identified previously and evidence was seen that some of this work has been undertaken and improvements made in several parts of the home. Some areas have been redecorated, the furniture replaced, furnishings renewed, and new carpets fitted, but some parts of the home still require attention. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 25 The following issues were discussed with the acting manager, and it was agreed that a detailed review of the premises will be done, and appropriate action taken to address all the findings: • • • • • • • • The programme of redecoration including the first floor bathroom, staff toilet and the corridors has not yet been completed The wallpaper in two recently decorated bedrooms was found to be peeling, and may be due to a recent roof leak The replacement of carpet in the dining area, the stairs and other areas of the house remains outstanding Some radiators have not been covered, and not all windows on the first floor have been fitted with an effective restrictor The laundry is functional, although small, but there is no wash hand basin fitted The area under the stairs is not satisfactory for its present purpose and also contains items that are no longer in use Some windows do not have either curtaining or a blind All doors do not close fully on to the rebates Several new items of equipment have been provided recently including a television, a fridge, two freezers, a cooker and a dishwasher. The equipment throughout the home was said to be in good working order, and the acting manager also confirmed that regular maintenance and servicing arrangements are satisfactory. Contracts are in place, and the records seen were all completed to a satisfactory standard, with the appropriate certificates available. The home is clean and fresh, and provides a suitable environment for the people who live and work there. Staff confirmed that they are familiar with the procedures regarding the control of infection, that guidelines are available, and that they have been given training in health and safety matters, which helps them to maintain satisfactory standards within the home. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home now has a more settled team of staff, who are able to ensure that the needs of people living at the home can be effectively met. The recruitment and selection procedures followed at the home help to ensure the protection of residents. The training and supervision available to staff ensures that they understand their role, and are able to provide appropriate care to the people they support, although 50 of the staff do not hold a NVQ in care at the present time. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 27 EVIDENCE: Staffing arrangements at the home have been more stable in recent months. Several staff had left when the home changed ownership a little over twelve months ago, which had been quite disruptive at the time, but the team is now more settled. The Registered Manager from The Brinton has been assisting the staff in the absence of the deputy manager, who is no longer employed by the company. The duty rota indicated that there is a minimum of two carers on duty throughout the waking day, with additional support for residents in their various activities in the community as needed, and the acting manager confirmed that the staffing levels are maintained at an adequate level for the needs of the people who live at the home. The residents are all male, and the acting manager said that as there is only one male carer working at the home, it is her intention to improve this ratio, when new staff are recruited. A thorough recruitment and selection procedure has been produced by the organisation. The staff file seen by the inspector provided evidence that relevant information is recorded and appropriate documentation is in place, which includes Criminal Record Bureau (CRB) checks, written references, a birth certificate and passport as proof of identity, and training certificates. Discussions with the staff on duty at the time of the inspection, about their experiences of working at the home, confirmed that appropriate recruitment procedures are followed, that they are given training opportunities, and that they feel supported by the management. A training programme is followed at the home. Induction is given to all new staff initially, and Learning Disability Award Framework (LDAF) training is also provided. Three staff are doing the National Vocational Qualification Level 2 in care, although this does not represent 50 of the current staff team. The records seen during the inspection confirmed that recent training provided for staff has included fire awareness, moving and handling, basic food hygiene, infection control and health and safety Care related training on abuse awareness, medication, challenging behaviour, epilepsy and adult protection has also been organised. The acting manager has identified the need for training to be arranged on nail care, communication, dementia care, death and bereavement and first aid. Formal supervision sessions, which include an annual appraisal, have now been introduced for all care staff, and these are undertaken regularly by the care manager, with a record of the content of the discussion maintained in their staff files. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is focussed on the best interests of the people who live at the home, but aspects of the management of the home including quality monitoring and the general organisation need to be further developed and implemented, in order to be more effective. The health, safety and welfare of service users and staff is promoted in respect of all safe working practices, to ensure that the people who live and work at the home are fully protected, although an emergency evacuation contingency plan for the home remains outstanding. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 29 EVIDENCE: The home has been without a registered care manager for several months, and the deputy manager had been responsible for the day to day running of the home, until recently when he resigned. Ms Haley Martin, who is the Registered Manager at The Brinton has been providing support and supervision to the staff team during this time. Concerns about the unsatisfactory situation in relation to the management arrangements at Mandeville House have been discussed with Mr Colin Farebrother, the Responsible Individual, who has confirmed that the Company will be recruiting a new manager in the near future. A quality monitoring system is being developed at the home, but has not yet been implemented. A quarterly audit report is completed that covers the management of the home, the premises and related documentation, care planning, staffing and administration, and an AQAA The views of residents, their family, advocates and professionals are sought through questionnaires, but the results now need to be audited and an annual report produced that measures how well the home meets the needs of the people who live there. The home has a policy that details how health and safety matters are to be addressed, and all staff are trained in safe working practices. The records seen had been completed to a satisfactory standard. Regular maintenance and servicing of equipment is undertaken, the service reports and certificates are all in order, temperature checks are recorded and accident records are maintained. The Fire Log was seen, and appropriate checks have been undertaken with the required frequency. Notifications are made under Regulation 37, which requires reports to be sent to the Commission of the death or serious illness, or any other event in the home which may adversely affect the wellbeing of a service user. The acting manager advised that an Emergency Evacuation Contingency Plan for the home was being developed, but had not yet been finalised, although the arrangements will include involvement with the other homes in the area belonging to the company. Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 2 X 2 X X 2 X Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 31 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 YA42 Regulation 13(4)(a) Requirement The risk to residents from exposed radiators must be assessed and appropriate action taken, to prevent any injury from contact burns The risk to residents from open windows which are not restricted must be assessed and appropriate action taken to prevent injury from falling Timescale for action 31/12/07 2 YA42 13(4)(a) 31/12/07 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 YA1 Good Practice Recommendations Further review of the Statement of Purpose should be undertaken to reflect the management arrangements and the revised Service Users Guide should be produced without delay to provide relevant information about the home The acting manager should ensure that for future admissions funded by the Local Authority, a Community Care Assessment is obtained prior to admission DS0000067880.V346642.R01.S.doc Version 5.2 Page 32 2 YA2 Mandeville House 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 YA6 YA9 YA12 YA14 YA15 YA21 YA21 YA22 YA24 YA28 YA30 YA32 YA37 YA39 YA42 The quality of life of residents will be enhanced by the on going development of the person centred approach to the delivery of care at the home In order to promote the safety of residents and enable them to have more independence, further development of the risk assessment process should be implemented Opportunities for involvement in more activities in the local community for residents who wish will further increase their enjoyment of life. The option of an annual holiday should be offered to each resident, and appropriate arrangements made to further extend their leisure opportunities Advocacy services for a resident without any immediate family should be arranged, to ensure that any decisions that need to made are in the best interests of the resident Consideration should be given to the wishes of every resident in regard to after death arrangements, to ensure these are managed appropriately and with sensitivity Training should be provided for staff on death and bereavement to ensure their understanding of the issues, and enable to respond to the situation effectively All comments, concerns and compliments made about the home should be recorded to provide a more balanced view of the service Ongoing improvements to the home should continue to be made for the benefit of the residents, specifically the replacement of furniture and furnishings as necessary Further work should be undertaken to the areas of the house and garden that need attention, to improve the facilities that are available for residents Consideration should be given to the laundry provision at the home, and the need for a hand washing facility to prevent the spread of infection Action should be taken to improve the percentage of staff with a NVQ in care to ensure that residents are supported by competent and qualified staff To ensure that residents benefit from a well run home the management arrangements should be addressed without further delay The quality assurance system, should be implemented fully to ensure that the home is run in the best interests of the people who live there Arrangements for the support and protection of residents in the event of an emergency should be recorded in an Emergency Contingency Plan for the home Mandeville House DS0000067880.V346642.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Worcester Local Office 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. 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