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Inspection on 28/06/05 for Mantley Chase

Also see our care home review for Mantley Chase for more information

This inspection was carried out on 28th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides people with challenging needs a quality service that allows them to lead active and fulfilling lives. Service users are assessed and care plans are in place to meet those identified needs and comprehensive risk assessments ensure they are protected and empowered. The premises provide the service users with space that exceeds the requirements of the National Minimum Standards.

What has improved since the last inspection?

The decoration of a service user`s flat has been improved greatly.

What the care home could do better:

Some of the service users` bedrooms could be decorated to a better standard and this is reflected in the requirements of this report. The manager must ensure that all service users sign their contracts.

CARE HOME ADULTS 18-65 Mantley Chase Ross Road Newent Gloucestershire GL18 1QY Lead Inspector Paul Chapman Announced Tuesday 28 June 2005 09:00 th 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 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 Stationary 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. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mantley Chase Address Ross Road Newent Gloucestershire GL18 1QY 01531 822112 Not known Not known Mr Rodney Correia, Homleigh Care Homes Limited Mrs Mary Badham Care Home - Personal Care 9 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Learning Disability (9) registration, with number of places Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13/01/05 Brief Description of the Service: Mantley Chase is a large detached property in extensive grounds. It offers accommodation for up to nine service users whose behaviour may challenge. The home has been adapted for it current purpose and opened in January 2004. The home have trainsport which enables them to make use of the local and surrounding areas. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over four and half hours on a day in June 2005. A few of the people living at the home are able to express their thoughts and feelings, others have limited verbal expression. Time was spent with two people living at the home and three other people were observed. Two members of staff were spoken to in addition to the registered manager. The group manager was present at the end of the inspection. A tour of the premises and grounds was conducted. The care of one person was examined in depth. Other records examined included service users’ files, daily diaries, staff files, health and safety records and policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 6 Some of the service users’ bedrooms could be decorated to a better standard and this is reflected in the requirements of this report. The manager must ensure that all service users sign their contracts. 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. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 standard(s) 1, 5 The home’s Statement of Purpose accurately reflects the current practices in the home and allow service users or their representatives to make an informed choice. EVIDENCE: No new service users have been admitted to the home since the previous inspection. A requirement of the previous inspection related to the home’s Statement of Purpose being updated to accurately reflect current circumstances. Examination of the document showed that this had been achieved. A recommendation of the previous inspection was for the manager/staff to record any trial visits to the home. The home has developed a “transition plan” which includes a form to be completed when prospective service users visit. As no new service users have been admitted it was impossible to judge whether this happens. This recommendation will be carried over in this report. Examination of a service user’s contract showed that it needed to be signed (others have been signed); this becomes a requirement of this inspection. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9, 10 Care plans meet the service users assessed needs and regular review allow staff to meet changing needs. Risk assessments minimise risks to service users and empower them to take risks that may improve their lifestyles. EVIDENCE: The service user’s file that was examined showed that they had comprehensive care plans to meet their assessed needs. These plans were regularly reviewed by staff and amended when required. Wherever possible service users are asked to sign documents in agreement. Evidence of regular review meetings was present. The manager stated that they are going to implement Essential Life Plans (ELP’s) with all of the service users. This will focus the approach of the care being provided on the wishes/assessed needs of the service users. As stated in a previous inspection report it is felt that this will give the home a comprehensive care package. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 10 Behaviour management plans were examined and seen to be appropriate to meet the needs of the service users. Staff have clear guidelines about indicators of behaviour escalation to be aware of, and actions to take to maintain the service users and their safety. Any incidents where restraint has been required are well recorded and all staff are trained appropriately. The records in the service user’s file showed they were supported to make choices and decisions over their own lives. Service users’ meetings were discussed, in particular their effectiveness and it was agreed that the manager should identify another format that may work more effectively. This is a recommendation of this report. The home has a “views” document which service users complete. A completed document was seen and the manager explained the steps they take if they find a service user believes there is a shortfall. Staff complete risk assessments for service users that minimise risks to their safety. All documents are stored securely in the home’s office. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16, 17 The home offers a flexible and individualised service that enables service users to lead varied and fulfilling lives. EVIDENCE: Service users confirmed that the home offers a very flexible and individualised lifestyle for them, giving them every opportunity to maintain and develop social, emotional, communication and independent living skills. A range of opportunities are available, including attending the local day services and College. Staff were able to give the inspector a number of examples of the local facilities used by the service users. These tend to be in Gloucester and service users use the transport provided by the home to access them. Staff were able to give examples of day trips that had been taken place recently. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 12 The staffing rota that was seen confirmed that the team are flexible about the times they work, enabling service users to take part in activities. The daily routines in the house are led by people’s needs and the service users and their records confirmed this. At the time of the inspection some of the service users had been on holiday whilst others were being arranged. Staff stated that service users enjoy the following activities: Sticking magazines, swimming, sewing, art and craft, colouring, walking, shopping, cooking, picnics, trampoline and going to the local pub. The home’s policy confirms that family and friends are welcome at the home, and people are able to see them in private if they wish to. At previous inspections staff confirmed that the service users are supported to maintain family links with varying degrees of assistance from them. Support may include help with making phone calls, writing letters/cards and providing transport and staff support where appropriate. Menus examined were seen to provide service users with choice and a healthy and varied diet. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 standard(s) 18, 19, 20 Effective management of service users medication ensures their safety. The home involves other professionals to ensure the needs of the service users are fully met. EVIDENCE: The manager stated they would be completing “OK health checks” with all the service users in the future. This is a government initiative to ensure that all service users with learning disabilities have their health needs addressed appropriately. Records seen in service users’ files showed that where the home is unable to meet a person’s physical and emotional needs other appropriate professionals are involved. Medication administration was examined and found to be managed correctly at the time of this inspection. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 standard(s) 22, 23 The home has an Adult Protection policy and new staff complete training in protection as part of their induction, which minimises any risk to service users. EVIDENCE: No complaints have been made since the previous inspection. Speaking to two service users they stated that they would be listened to if they made a complaint. Two new staff were spoken to by the inspector. Both were able to explain the correct process to follow if they witnessed abuse or an allegation of abuse was reported to them. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 30 The home has large communal areas which allows each service user shared space in excess of the minimum standards. The home is maintained to a good standard which enables service users to live in a safe environment. EVIDENCE: Areas of the environment identified in the previous report as requiring decoration/refurbishment have been addressed. The premises provide the service users with large communal areas that include a kitchen/diner, lounge, music/quiet room and a conservatory. In addition to this the home has extensive grounds that have a summerhouse, trampoline and swing. The home also keeps chickens and some goats. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 16 The standard of decoration in the communal areas is good, and the home was clean and hygienic at the time of the inspection. A requirement of the previous inspection related to the home decorating a person’s flat. Inspection of these rooms at this inspection showed they had been decorated recently with only the bedroom still requiring decoration. The manager stated that in the days following the inspection a new floor covering was due to be laid. Some shortfalls were identified while inspecting the toilets/bathrooms and service users bedrooms. These included: Upstairs bathroom – area around the toilet needs to be addressed. P’s bedroom – must be decorated as it looks a little “tired”. D’s Bedroom – the manager must ensure that the service user has curtains that meet their needs (the service user tends to pull the curtains down). C’s Bedroom – the manager stated they were going to ask the proprietor to decorate this room. All of the bedrooms were seen to be personalised by the people that live in them. In conversation with two of the service users they stated that they liked their bedrooms. The home has its own dedicated maintenance person who is responsible for completing any repairs around the home. None of the service users require any specialist equipment to maximise their independence. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36 Recruitment and induction training of new staff is thorough to ensure risks to service users are minimised. EVIDENCE: All staff have job descriptions. Two staff recently employed were spoken with during the inspection. Each one had completed induction training as well as other courses relevant to meeting the needs of the service users (e.g. Diabetes and behaviour management). One person is currently completing their NVQ level 2 whilst the other is waiting to start their NVQ 3. Training records of the staff members were not examined in depth on this occasion, however the manager must ensure that staff files have up to date records of their training certificates in the future. The personal file for the newest member of staff was examined and showed one shortfall that was discussed with the manager who assured the inspector this would be addressed. Both new staff had had CRB checks completed. Both staff stated that they received regular supervision. Minutes from staff meetings showed that they were held every other month. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 42 The manager’s leadership of her team with the support of relevant policies and procedures allows service users to live in a safe environment. EVIDENCE: The manager has considerable experience in working with this service user group and is appropriately qualified with the Registered Manager’s Award. Staff spoken to during the inspection stated they felt the senior support workers and the manager were approachable. The home has extensive policies and procedures in place to protect the service users. As identified earlier in this report the home has a monitoring form for service users to complete which asks for their views of the practices in the home. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 19 The manager ensures that health and safety checks are completed at the appropriate intervals. These include portable appliance testing, monitoring fridge/freezer temperatures and fire alarms. Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 2 3 N/A 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mantley Chase Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x 3 x D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 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 5 Regulation 5(1)c Requirement The manager must ensure that all service users, or their representatives sign their contracts. The manager must ensure that Ps bedroom is decorated. The manager must ensure that Ds bedroom curtains are affixed properly. The manager must ensure that Cs bedroom is decorated. The manager must ensure that the area around the toilet in the bathroom is made good. Timescale for action 19/08/05 2. 3. 4. 5. 6. 25 25 25 27 23(2)d 23(2)d 23(2)d 23(2)d 30/09/05 30/09/05 30/09/05 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 4 7 Good Practice Recommendations The manager should record occasions when prospective service users visit the home for a trial run. The manager should investigate and implement a different format to enable service users to express their opinions as it is felt that the resident meetings are ineffectual. Version 1.30 Page 22 Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 Mantley Chase D51_D03_S49949_MantleyChase_V229511_280605_Stage4.doc.doc Version 1.30 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!