Inspection on 11/07/06 for Mansion House

This inspection was carried out on 11th July 2006.

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

The inspector found 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mansion House 05/02/08

Mansion House 04/10/05

Mansion House 28/04/05

Mansion House 15/11/04

Mansion House 10/05/04

Similar services:

Dovedale Court

Lyncol House

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Mansion House 15 Mansion Row Brompton Gillingham Kent ME7 5SE Lead Inspector Robert Pettiford Unannounced Inspection 11th July 2006 09:30 Mansion House DS0000028936.V303176.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 Mansion House DS0000028936.V303176.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. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansion House Address 15 Mansion Row Brompton Gillingham Kent ME7 5SE 01634 841280 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) Kent Assessment Training Services (Medway) Post Vacant Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: Mansion House is a large detached Victorian property, located in a residential area on the outskirts of Chatham and Gillingham town centres. It is a 15 bedded home that provides 24 hour care to adults who have a learning disability and present challenging behaviour. The Service User accommodation is sited on 3 floors, all bedrooms are single and there are ample communal areas. Bathing and toilet facilities are located on all floors. There is a garden to the rear of the property that is easily accessible to the Service Users. The front garden is laid to lawn and this also provides parking facilities for staff and visitors. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 11th July 2006 at 9:30am. The Inspector agreed and explained the inspection process with the Manager. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. A tour of premises was also undertaken. The focus of the inspection was to assess Mansion House in accordance to the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. Time was spent by the inspector observing service users in their daily activities and discussing the standard of care within the home with the Manager and staff. The scale of charges for Mansion House range from £880.00 to £2,300.00 per week. What the service does well: What has improved since the last inspection? It was evident through the inspection process that the manager is taking appropriate steps to improve the standards of care within the home. Since her appointment adult protection and safety of service users has been seen as a priority alone with staff training. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mansion House DS0000028936.V303176.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 Mansion House DS0000028936.V303176.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, Quality in this outcome group is good Prospective service users on the whole have all the information they need to make an informed choice about whether they wish to live at the home. Service users can be confident that their needs will be suitably assessed and that they will have the benefit of a trial period at the home prior to moving in. EVIDENCE: The home has a Statement of Purpose. The manager stated that it meets with the required standards, and includes all the information as required of Schedule 1 of the Care Home Regulations 2001. The manager is currently preparing service users guide’s that are in a format that is appropriate for all the service users living within the home. Several Care plans were viewed some contained pre assessments and appeared to contained all of the information needed to make an informed decision as whether the home would be able to meet the prospective service users needs. However not every care plan viewed contained such an assessment. Key to achieving an individually appropriate lifestyle is the Service User Plan, determined by assessment and drawn up between the home and the service user. Therefore a detailed assessment is needed to draw up such a plan of care. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 9 The home does encourage prospective service users to come to the home for the day and have a meal, they also invite for an overnight stay. All service users coming into the home do so on a trail basis, during this time the assessment continues and the service user has the opportunity to see if they are happy at the home. If at the end of this period the home feels it can meet the service users needs and the service user is happy then the placement can become permanent. Mansion House DS0000028936.V303176.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome group is adequate Service users benefit from having individual plans that identify their physical and medical needs, but were found to be in need of updating and review. Service users cannot feel fully confident that they are fully supported to take risks within a risk assessed framework. The service users can be confident that their rights to make decisions about their lives is respected and they are consulted on, participate in, all aspects of life within the home as they wish. EVIDENCE: The inspector viewed and discussed with the Manager the care records relating to several service users. In the care plans viewed there were clear guidelines in respect to support needed with regard to strategies to manage and support service users with their challenging behaviour. Plans sampled demonstrated that the home used positive planned interventions to manage behaviour. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 11 The home undertakes reviews, but due to the change in the management of the home care plans were found to be in need of updating and reviewing. The new manager was aware of this and intends to ensure that such reviewing takes place. No evidence was available that service users were involved in drawing up personal care plans in the documentation seen or that they are consulted in reviewing and amending such care plans, although they are invited to their review should they wish to attend. The home and its staff are committed to supporting the service users in accordance with their needs Mansion House. This was evidenced through the knowledge and experience of the staff seen by the inspector whilst supporting several service users. The care plans viewed draws in all the information into one document to assist the care worker in delivering the care. It covered and included the following headings. Needs (What are the assessed needs?) Objectives (What do you want to achieve? Action (Agreed action and by whom?) Comments, Review Date It is evident through talking to members of staff that the emotional health of the service users is of a high priority to the home and that staff are pro-active in maintaining and supporting Service Users with their emotional needs in order to maintain their quality of life. Service users with communication difficulties did not have any form of communication package developed from professional input to support care staff. The home was requested to develop more structured forms of communication to both assist the service user and promote consistency with care staff. Risk assessments were discussed and viewed with the manager. Documentation recorded how to support service user’s to minimise risks for personal safety. However not all care plans viewed contained all necessary risk assessments and were not regularly updated. The home needs to demonstrate that any situation where a service user could be at risk to themselves or others is suitable risk assessed and reviewed. Mansion House DS0000028936.V303176.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome group is excellent Service users can be confident that they are offered opportunities for personal development and to learn new skills and feel part of the wider community. Service users engage in a higher than average level of activities which are appropriate to their needs. Service users are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The service users benefit from the appetising meals and balanced diet offered at the home. EVIDENCE: Service users are enabled to participate and contribute to meeting their own self care needs and day to day chores around the house although as previously evidenced this was not reflected in the care plan. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 13 Discussion with the Manager and staff confirmed that the level of activities were of a high level and good quality for all of the service users and that they enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home. Service users have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining and building on personal collections and specific recreational activities. It was confirmed that service users are enabled to maintain contact with relatives and friends where they wished to do so. Examples of such included provision for relatives and friends to visit the home and support being provided to enable services users to visit relatives or friends outside the home. Service users were consulted with regard to whom they saw and when and were under no compulsion to accept visitors should they not wish to do so. None of the service users who were discussed about with staff had any spiritual needs which they actively addressed, however it was confirmed that where this was the case all appropriate support would be provided. From observation, records viewed it was evident that service users were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the service users’ activities and schedules. Service users are able to choose where to eat, and also have facility to make drinks, meals and snacks for themselves and others with staff support should they wish. Service users on evidence seen have had been involved in planning and choosing menus. Mansion House DS0000028936.V303176.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Quality in this outcome group is good Service users feel supported by the level of help given and that their healthcare needs are addressed. EVIDENCE: Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different service users daily routines. Service users were able to make their own choice where possible with regards to what they wished to wear and their hairstyles and this was evident by their individual appearance. The inspector observed excellent interaction between staff and service user’s. The homes records fully documented all physical and emotional healthcare needs which is monitored on a daily basis. Records of health care provided by G.P, chiropodist, dentist, and opticians were evidenced. This system ensures that all service user’s receive continuity of care and support and that potential complications and problems are recognised and dealt with at an early stage. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 15 Staff actively promote the service users right of access to the health and remedial services that they need, both within the home and in the community. Regular appointments are seen as important and there are systems in place to make sure residents are reminded and appointments are not missed. Mansion House DS0000028936.V303176.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome group is good. Service users rights with regard to making a complaint are protected within the home however the complaints procedure is not available in formats that are suitable for all service users. Service users can feel confident that they are protected from abuse within the home. EVIDENCE: A copy of the Home’s complaints procedures was inspected within the home and found to meet with the National Minimum Standards. However it was not available in different formats that meet with all the service users needs. The home was requested to ensure that it is made available in different formats. The home’s Policy for the Protection of service users and staff “Whistle blowing” procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided in adult abuse for all staff. The home did possess a copy of the Kent and Medway Adult Protection procedures / protocols. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Quality in this outcome group is adequate. Service users benefit from living in on the whole a clean comfortable home, which is suitable for their needs. EVIDENCE: The Inspector undertook a tour of the home including viewing some service users rooms, bathroom/toilet facilities and communal areas. Fixtures and fittings and general decoration were seen to be of a variable quality. Some remedial work was seen as being needed due to the demands placed on the building by the service user group The home is intending within the next six month’s to replace the kitchen and move the laundry room and decorate service users bedrooms and communal area’s. This will improve significantly the environment and should result in improved standards. The manager was requested to consult with service users with regard to colour scheme’s etc and involve them in this process to promote a homely atmosphere within the home. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 18 The bedrooms are very well planned and seen to be personal in nature with each service users expressing their own identity. The number of toilet and bathroom facilities provided by the Home meets current required standards Mansion House DS0000028936.V303176.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35 Quality in this outcome group is good Inspected at the random inspection on the 20th April 2006 EVIDENCE: Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 Quality in this outcome group is good Whilst the quality of care offered to service users is on the whole sound, it will be better promoted once a full-time Registered Manager is appointed to run the home. Service users can feel fully confident that their health and safety/ welfare is protected by robust policies/ procedures and safety checks. EVIDENCE: The home currently does not have a Registered Manager. The management of the home is supported by a manager who has recently been recruited who previously worked as a Registered Manager within the same group of home’s. The manager was requested to include within the home’s action plan on how the home intends to ensure that it has a Registered Manager Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 21 The inspector viewed records relating to staff training, Health and Safety Procedures, maintenance and servicing, and risk assessments, which were discussed with the manager. Staff training requirements had been identified and arrangements for staff to undertake the required training relating to health and safety. The inspector was able to evidence that the home had a Fire Log book, reflecting that checks and servicing of fire safety equipment had been undertaken at the required frequency. Procedures are available for the reporting of accidents and incidents (Regulation 37) and records maintained of the same. The home was able to evidence that COSH (Containment of Substances Hazardous to Health) assessments and data sheets were in place and an environmental risk assessment. Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x 2 x x x x 3 x Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement 15. - (1) Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (the service users plan) as to how the service users needs in respect of his health and welfare are to be met. (2) The registered person shall (a) make the service users plan available to the service user; (b) keep the service users plan under review; (c) where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 24 Timescale for action 11/10/06 plan; and (d) notify the service user of any such revision. 2 YA9 13 13. - (1) The registered person shall make arrangements for service users (4) The registered person shall ensure that (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, 3 YA24 23 23.—(2)(b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; 9 - (1) A person shall not manage a care home unless he is fit to do so. (2) A person is not fit to manage a care home unless (a) he is of integrity and good character; (b) having regard to the size of the care home, the statement of purpose, and the number and needs of the service users (i) he has the qualifications, skills and experience necessary for Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 25 11/10/06 11/01/07 4 YA37 9 11/09/06 managing the care home; and (ii) he is physically and mentally fit to manage the care home; and (c) full and satisfactory information is available in relation to him in respect of the following matters (i) the matters specified in paragraphs 1 to 5 of Schedule 2; (ii) except where paragraph (3) applies, the matters specified in paragraph 7 of that Schedule; (iii) where paragraph (3) applies, the matters specified in paragraph 8 of that Schedule. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mansion House DS0000028936.V303176.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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