Inspection on 04/10/05 for Mansion House

This inspection was carried out on 4th October 2005.

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

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

Other inspections for this house

Mansion House 05/02/08

Mansion House 11/07/06

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 Announced Inspection 4th October 2005 09:30 Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 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.V255992.R01.S.doc Version 5.0 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.V255992.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mansion House Address 15 Mansion Row Brompton Gillingham Kent ME7 5SE 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 (Meway) Vacant Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 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 large 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.V255992.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection at Mansion House took place on 4th October 2005 at 10:00am. The Inspectors agreed and explained the inspection process with the Manager. Documentation and records were read, including care plans. 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. What the service does well: What has improved since the last inspection? What they could do better: Recruitment procedures were seen to be in need of review to ensure that it meets with standards. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 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. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 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.V255992.R01.S.doc Version 5.0 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): 1,2,3,4,5 Service users have the information they need to ascertain whether the home can meet their needs. Service users’ rights are protected by a written contract and they have the benefit of a trial period at the home prior to moving in. Service users can be confident that their needs will be properly assessed prior to moving to the home. EVIDENCE: The Statement of Purpose and Service Users guide for Mansion House was seen to include the information outlined in the standards. The Manager reported that a copy of the previous inspection reports are made available to service users and their families on request. A written contract / statement was available outlining service users’ rights, responsibilities, and conditions of placement is in place. Records held showed that service users undergo an assessment which identifies their individual needs prior to admission to the home. The information is provided by the service users, their families and health / social care professionals. This is then reflected into the care plans and these are developed in agreement with the individual. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 9 The records also reflected that there may be a transitional period for new service users and ongoing assessments to meet the changing needs were evidenced within service user records. Prospective residents have the benefit of a trial period at the home to assess whether the home can or cannot meet their needs. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 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): 6,7,9 Individual plans are comprehensive identifying needs and personal goals and are specific to the individual service user. Care plans showed that service users are enabled to make decisions and choices. Service users are enabled to take responsible risks through a thorough risk assessment process. EVIDENCE: The home is committed to supporting the service users in accordance with their needs. This was evidenced through the care plans which detailed the areas of support that the service user needed and how this support is provided by the staff. The manager confirmed that these are reviewed with the service users on a regular basis and the families are supported to be involved. All care plans viewed had short and long-term goals, which had been agreed with the individual. Service users’ rights to make decisions are respected and the care plans reflected their ability to make an informed judgement. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 11 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. Risk assessments were discussed and viewed and detailed documentation recorded how to support service users in their daily living activities and identified how to minimise risks for personal safety. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 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): Not inspected on this occasion. EVIDENCE: Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this occasion. EVIDENCE: Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 14 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): Not inspected on this occasion EVIDENCE: Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 15 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 Service users benefit from living in a clean comfortable home, which is suitable for their needs. EVIDENCE: The Inspector undertook a tour of the home including some service users rooms, with their permission, bathroom/toilet facilities and communal areas. All areas viewed appeared bright, cheerful, and airy. Fixtures and fittings and general decoration were seen to be of a good standard, The house was homely and central to amenities. The living areas and kitchen were found to be clean and tidy. The seating in the lounge was comfortable and thought had been given to making the area look like any other sitting room. Laundry facilities are domestic in nature and currently do not meet with the needs of all service users. This has been identified as a shortfall by the manager prior to the inspection and steps are being taken to ensure that facilities meet with service users needs. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 16 Bedrooms were 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. Toilets and bathrooms were lockable offering service users’ privacy, although staff are able to access toilets/bathrooms in an emergency if required. The home employs a handyman. It was evident that some of the rooms had been decorated since the last inspection. The manager explained that this was ongoing. Work has also been carried out in the garden to make it safer and provide a more inviting environment. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 17 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): 34 Service users are not protected by the recruitment procedures within the home. EVIDENCE: The inspector viewed details of the home’s recruitment procedure and a number of records relating to staff members recruited within the last year. Not all the files contained two references, proof of identity, confirmation of work status and all the information as required under schedule 2 of the Care Home Regulations 2001. The home needs to show that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of I.D and copies of qualification certificates, seeks two written references, confirms work status and also undertakes some telephone checks and retains all the information as required under schedule 2 of the Care Home Regulations 2001. The manager agreed to address this within the homes action plan. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 18 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): 39,42 Service users can be confident that the home’s practice is monitored through various quality assurance methods. Systems and checks are in place to insure that service users and staff are safe within the home as far as possible. EVIDENCE: Quality Assurance methods used at the Home include, individual service user feedback, feedback from staff and residents at meetings, social services and CSCI inspections, internal audits and reg 26 provider visits. Service users were aware of the inspectors visit and the manager reported that they had advised relatives of the inspection. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 19 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 in Health and safety, First Aid and Food Hygiene had been identified and arrangements for staff to undertake the required updates (awaiting confirmation training dates Procedures are available for the reporting of accidents and incidents (Regulation 37) and records maintained of the same. Some additional training was identified as being needed with regard to infection control. This was recognised by the manager who agreed to include it in the home’s action plan. Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mansion House Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x DS0000028936.V255992.R01.S.doc Version 5.0 Page 21 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 YA34 Regulation 19(1) Requirement 19.—(1) The registered person shall not employ a person to work at the care home unless— (a) the person is fit to work at the care home; (b) subject to paragraph (6), he has obtained in respect of that person the information and documents specified in— (i) paragraphs 1 to 6 of Schedule 2; (ii) except where paragraph (7) applies, paragraph 7 of that Schedule; (iii) where paragraph (7) applies, paragraph 8 of that Schedule; and (c) he is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person. (2) This paragraph applies to a person who is employed by a person (“the employer”) other than the registered person. (3) This paragraph applies to a position in which a person may in the course of his duties have DS0000028936.V255992.R01.S.doc Timescale for action 04/01/06 Mansion House Version 5.0 Page 22 regular contact with service users at the care home or with any other person of a description specified in section 3(2) of the Act. (4) The registered person shall not allow a person to whom paragraph (2) applies to work at the care home in a position to which paragraph (3) applies, unless — (a) the person is fit to work at the care home; (b) the employer has obtained in respect of that person the information and documents specified in— (i) paragraphs 1 to 6 of Schedule 2; (ii) except where paragraph (7) applies, paragraph 7 of that Schedule; (iii) where paragraph (7) applies, paragraph 8 of that Schedule, and has confirmed in writing to the registered person that he has done so; and (c) the employer is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person, and has confirmed in writing to the registered person that he is so satisfied. (5) For the purposes of paragraphs (1) and (4), a person is not fit to work at a care home unless— (a) he is of integrity and good character; (b) he has qualifications suitable to the work that he is to perform, and the skills and experience necessary for such work; (c) he is physically and mentally Mansion House DS0000028936.V255992.R01.S.doc Version 5.0 Page 23 fit for the purposes of the work which he is to perform at the care home, and (d) full and satisfactory information is available in relation to him in respect of the following matters— (i) each of the matters specified in paragraphs 1 to 6 of Schedule 2; (ii) except where paragraph (7) applies, each of the matters specified in paragraph 7 of that Schedule; (iii) where paragraph (7) applies, each of the matters specified in paragraph 8 of that Schedule. (6) Paragraphs (1)(b) and (5)(d), in so far as they relate to paragraph 7 of Schedule 2, shall not apply until 1st April 2003 in respect if a person who immediately before 1st April 2002 is employed to work at the care home. (7) This paragraph applies where any certificate or information on any matters referred to in paragraph 7 of Schedule 2 is not available to an individual because any provision of the Police Act 1997 has not been brought into force. 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.V255992.R01.S.doc Version 5.0 Page 24 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.V255992.R01.S.doc Version 5.0 Page 25 - 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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