Inspection on 29/11/07 for Mantley Chase

This inspection was carried out on 29th November 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 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mantley Chase 24/01/07

Mantley Chase 09/01/06

Mantley Chase 28/06/05

Mantley Chase 14/01/05

Mantley Chase 23/09/04

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

CARE HOME ADULTS 18-65 Mantley Chase Ross Road Newent Gloucestershire GL18 1QY Lead Inspector Mr Paul Chapman Key Unannounced Inspection 29 November 2007 and 4th December 09:00 th Mantley Chase DS0000049949.V344834.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 Mantley Chase DS0000049949.V344834.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. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mantley Chase Address Ross Road Newent Gloucestershire GL18 1QY 01531 822112 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) www.holmleigh-care.co.uk Holmleigh Care Homes Ltd Mrs Mary Ann Theresa Badham Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Mantley Chase is a large detached property in extensive grounds. It offers accommodation for up to twelve service users whose behaviour may challenge. The home has been adapted for it current purpose and opened in January 2004. The home has access to transport which enables them to make use of the local and surrounding areas. Since the previous inspection the provider has converted the coach house in the grounds to provide accommodation for three service users. This building was registered with the CSCI last year. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This site visit took place in November and December 2007 and included two visits to the home were on November 29th and 4th of December. The registered manager was in attendance throughout the visits. An AQAA (Annual Quality Assurance Assessment) was completed by the manager prior to the site visits. Completed surveys were received from four people living at the home, six parents and four healthcare professionals. Time was spent observing the care of people and their interactions with staff. Four people living at the home were spoken to and several people’s rooms were inspected on their invitation. The care of three people was looked at in depth that included looking at their financial, medication and personal records. Five staff were interviewed about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: The home complete a thorough assessment of people’s needs before they move into the home. People are supported to learn new skills and become more independent. People living in the home lead active and varied lifestyles supported by staff were required. People living in the home are confident that they can make complaints if they are unhappy and that staff will listen to them. Members of staff showed a good awareness of how to support people with limited communication to make a complaint if they were unhappy. Observed interactions between the staff and people living in the home were positive and respectful. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Mantley Chase DS0000049949.V344834.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 Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People admitted to the home are thoroughly assessed before they are offered a place to minimise the risk of people moving in whose needs cannot be met. EVIDENCE: Since the previous inspection was completed 1 person has been admitted to the home. This process was examined in detail. It showed that the manager had obtained a recent assessment from the person’s funding authority and completed their own assessment of the person’s needs. To support this assessment staff from the home visited the person in their previous placement working with staff and observing the person for 2 days a week. As well as staff visiting the previous placement at different times of the day the person visited the home before they moved in. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care plans seen highlight people’s needs but are not person centred and provide little evidence of people living in the home being involved in their development. Staff support people to become more independent but poor recording makes it difficult to evidence exactly what input the staff provide. Potential risks to people are minimised through the risk assessments completed by the staff team. EVIDENCE: The care of three people living in the home was examined in detail. This involved reading care plans, reviews and other associated documents. Where possible people were spoken with. The files examined contained care plans for each person that covered needs around communication, family contact, activities, eating and drinking, Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 10 maintaining a safe environment, personal hygiene, self-harm and money management. The manager stated that they plan to review the format for all of the care plans in the New Year to make them more person centred. The home has a system where key workers/staff complete a monthly review of people’s care and the activities they are involved in. At the time of this site visit this was not being achieved consistently and the deputy manager was in the process of writing up a number of the out of date reviews. They stated that due to staff leaving they had fallen behind, but would be up to date by the New Year. The reviews seen provide a good picture of what happens from day-today, but as highlighted in the previous inspection report staff must be careful with the recording in these reviews. Staff should record exactly what people have done, not just write “in house activities”. A PCP is a Person Centred Plan. Person Centred Planning puts the ‘person’ at the centre of a planning process and shifts power to them. It provides an effective way to listen and respond to people. The approach encourages us to take direction from people by identifying their gifts, interests and desires. This makes it different from traditional approaches to assessment and individual planning. The files examined contained PCP’s that had been started by staff but were incomplete. The manager stated that this would be addressed in the New Year. Speaking to one person living in the home they explained how they had been able to make a decision about their life. They gave the example of wanting to become more independent and explained how the staff had helped them achieve this. The person was really proud of their achievement. Examining the person’s file there was no written evidence of the steps taken by the staff team to achieve this. This was discussed with the manager and the need to write up the support the team had provided. It was clear that team’s input had supported the person to become more independent whilst maintaining the person’s safety. This becomes a good practice recommendation of this inspection report. Speaking to other people living in the home they were able to give examples of being involved in the day-to-day running of the home. These included choosing the menu for each week and the activities they were involved in. At the time of this site visit 1 person was being supported by a member of staff to do some cooking in the main house. Speaking to people living in the coach house they explained that they take it in turns to cook the meal each night with staff support. Each of the files examined contained risk assessments covering different areas of people’s lives. This enables people to take acceptable risks from day to day. Where required actions were highlighted to minimise potential risks to people. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 People who use the service experience good quality outcomes in this area. Staff support people to lead active lifestyles that meet their current needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Speaking to members of staff, people living in the home and examining records showed that various activities take part on a regular basis. People attend day services called “Star 66” in Gloucester managed by the home provider. People said that whilst attending day services they are able to do some cooking, art and craft and play some games like pool and table tennis. Staff from the home support people to attend the day service. One person spoke about attending college until recently. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 12 People attend two local social clubs regularly. Staff support small groups to go walking locally in the Forest of Dean and the Malverns regularly each week. Staff support people to use local amenities in nearby Newent. Two people living in the coach house use these amenities independently. One person spoke about going to the local pub by themselves the weekend before this site visit was completed. Staff support other people to go out for drinks/meals in pubs and restaurants. The home has its own transport and this enables people to use other facilities in Gloucester and Cheltenham. People spoken with explained that they enjoy going to a car boot sale regularly on Sundays. People have had various holidays this year. Speaking with one person they explained that they used to have a job when they lived at a previous place. They said that they would like to get another job and this information was fed back to the manager. 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 too. Staff confirmed that people 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. CSCI Surveys completed by relatives confirmed that they felt welcome to visit the home. Menus were examined and seen to provide people with choice and a healthy and varied diet. The main house and coach house have separate menus. One of the people living in the coach house explained that they choose the menu between them, “but sometimes we just choose something from the freezer”. They also said “I enjoy cooking”. Staff stated that sometimes the main house would cook meals for the coach house. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans to address people’s personal care needs are not person centred and it is difficult to assess whether they take into account people’s wishes. Staff in the home, or other professionals with the appropriate specialist skills are meeting people’s physical and emotional needs. Medication administration highlighted some shortfalls that may put people in the home at unnecessary risks. EVIDENCE: A number of the people living in the home require staff support to maintain their personal care. As identified earlier in this report the manager and deputy intend to review all of the care plans and make them more person centred. As part of the next inspection these plans will be examined to ensure that enough detail is present to provide a consistent approach. The files examined contained completed O.K. health checks (these identify what each persons health needs are and the support they require). All of the Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 14 files seen also contained correspondence from other healthcare professionals. CSCI surveys completed by healthcare professionals highlight some previous issues around communication and staff meeting people’s needs, but recognise that this has improved and that ongoing training is needed to continue this. To meet the needs of a person living at the home staff have recently completed, or will be completing training in buccal medazolam (emergency medication for epilepsy). A specialist epilepsy nurse provided this training and certificates for staff were seen. A number of the staff are new in post at the home and as yet have not completed their mandatory safe handling of medication course. The manager asked for guidance about whether these staff could administer buccal medazolam after receiving the specialist training. Guidance from a CSCI pharmacist inspector, and from speaking to the nurse who provides the training it has been agreed that staff who have successfully completed the specialist training, including a course in epilepsy can administer buccal medazolam without completing their mandatory training. Examination of medication administration within the home showed that on the whole it was well managed. Some shortfalls were identified and brought to the attention of the manager: • Topical creams must be labelled with the date the date they are opened. This requirement is carried over from the previous inspection report. • Hand written medication instructions on administration sheets must be signed by the member of staff writing them. • Where medication has been discontinued staff must make it clear on the medication sheet, again the staff member must sign this. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. People are able to make complaints if they are unhappy with the service they are receiving and the management team act promptly and professionally to address issues. Practices and records provide evidence that people living in the home are being protected from harm. EVIDENCE: The people living in the home have a wide range of needs and some people’s communication skills mean that it would be difficult for them to use the home’s complaints procedure. Three people living in the home were asked about the home’s complaints procedure, whether they knew there was one, had they used it and if they had were they satisfied with the outcome. All 3 of the people spoken to were aware of the complaints procedure, 1 person had used the procedure and was satisfied with the outcome. Another person said that they felt if they were unhappy they could make a complaint and it would be dealt with properly and they would be listened too. As previously mentioned a number of people have varying degrees of communication difficulties and 4 of the staff spoken to by us were asked about how these people could make a complaint. All of the staff were aware that people may display behaviours to show that they were unhappy, and that when they recognised this they would inform 1 of the senior staff or the manager. This showed a good insight into how people who may not be able to say they are unhappy are still protected. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 16 The AQAA completed by the manager stated that 1 complaint had been received in the previous 12 months and this had been resolved within 28 days. The CSCI received a copy of this complaint that was investigated by Gloucestershire’s Community and Adult Care Directorate. The findings of this investigation did not hold up the allegations. As part of the staff team’s mandatory training staff complete training in safeguarding adults. Staff complete training in behaviour management techniques and records are kept of all incidents where staff use these techniques. These records were examined and provided a good level of detail about the incident and actions taken. When these incidents occur the home’s manager informs the CSCI via a regulation 37 notification. None of the people living in the home manage their own money. Speaking to 2 people about this they said they were happy with this arrangement as it helped them to save some money. Both people agreed that they could have their money when they wished. Records for income and expenditure were examined for a sample of the people living in the home. All amounts and records seen were correct, where possible receipts were provided. Staff checks all monies twice a day at shift handover. Mantley Chase DS0000049949.V344834.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides people with a homely environment but unfortunately due to the maintenance issues around the home they are being put at unnecessary risks. EVIDENCE: Mantley Chase is an old large detached house that stands in its own considerable grounds. It is a good size and provides the people living there with more than ample communal and personal space. Since the home has opened the provider has also converted the coach house into additional accommodation for up to 3 people. In the garden of the property is an area that one person intends to grow vegetables in next year. In addition to this there is a summerhouse and a trampoline. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 18 A tour of the premises was completed with the manager of the home. At the top of the property is a flat used by 1 person. Although this flat looks bare it meets the needs of the person living in it, as they are unable to tolerate pictures and curtains hanging on the walls. The manager stated that that they plan to introduce murals on the wall. The following shortfalls were found: • A piece of floor covering was missing; this was reported to the provider in April 2007 (entry in maintenance book). Where the floor covering was missing the fixings/gripper was still in place with sharp metal protruding (This was removed by maintenance whilst we were completing the site visit). The manager stated that it was planned that the floor would be tiled but there was no date for this. This becomes a requirement of this inspection report. • The paint and decoration of the flat is poor, and it must be decorated throughout. This is an outstanding requirement of the previous inspection report. Other issues identified whilst completing the tour of the premises include: • • • • One bedroom on the 2nd floor had some water damage from the flat upstairs (this was repaired by the 2nd day of this site visit). But the room’s decoration is poor and needs to be re-decorated. One bedroom smells of faeces and this must be addressed by replacing the carpet floor covering. Main bathroom – Door lock broken making it impossible to lock. This room is also looking quite tired and in need of decoration. A requirement of the previous inspection report was for the bedroom with a damp problem above the window to be repaired. Visiting this room on this occasion showed this area has been re-plastered in February 2007 (entry in maintenance book), but as yet, not decorated. These repairs must be completed. Bedroom at the end with bathroom. Bulbs in the light fittings were blown and must be repaired. Staff must monitor this to ensure that the room is not left in darkness which may then pose a risk to the person using the bathroom. Tops of stairs. What appears to be a bed frame has been cut up and fixed together to make an additional safety rail/fence. This has sharp edges protruding. All of the sharp edges must be addressed. At present pieces of wood have been slide into the holes to try and stop people from being able to cut themselves. The manager stated that the provider has ordered a purpose made wrought iron rail/fence but they no idea when it is due to be delivered. Downstairs shower room. The doorframe is split and should be repaired. Downstairs bedroom. The wall has been plastered to repair some previous damage but still remains unpainted. This must be addressed. DS0000049949.V344834.R01.S.doc Version 5.2 Page 19 • • • • Mantley Chase • • • Laundry room. There is an area of wall above the door where the plaster is missing, this must be repaired. In addition to this there was a fire extinguisher in the laundry with no label making it impossible to confirm whether it had been serviced. Also, the ceiling in the laundry is bowing and is in need of repair. In the kitchen a large “wooden barrier/fence” has been put up between the cooking and eating area. The manager stated that this had been put up due to a person who would be at risk by entering the kitchen. Unfortunately the barrier/fence has not been painted/varnished and is a potential food hygiene hazard. This must be painted or varnished. Dining room floor. Is a wooden and in need of re-varnishing. Downstairs people have access to a good-sized lounge with a TV and DVD player and a range of chairs and sofas. In addition to the lounge there is also a quiet room with a range of furniture, from this room people can access a large conservatory to the rear of the property. At the time of this site visit an immediate requirement was left for the manager/provider to address the doors to both of these rooms. Both doors have been replaced recently and are fire doors, unfortunately neither door fits the doorframe, 1 did not even have a latch. The immediate requirement gives the provider 28 days to address this. Another immediate requirement was made. This was due to a shortfall identified by the fire officer. After a fire in the coach house a number of months ago the fire officer recommended that a thumb lock was added to a fire escape in 1 person’s bedroom. This has not been done and as a result an immediate requirement was made. The immediate requirement gives the provider 28 days to address this. The bedrooms seen were all personalised with people’s possessions. One person has a really nice 4-poster bed, a walk in wardrobe and is decorated in colours that they chose. The coach house is a purpose built property for up to 3 people. Accommodation is provided across 1 floor with people having access to a communal area providing a lounge/diner and kitchen area. Each person has a bedroom, lounge and en-suite bathroom. The coach house is pleasantly decorated and well maintained. Speaking to people living in the home they stated that they do their own washing, but unfortunately do not have their own washing machine/tumble dryer which means they have to use the facilities in the main house. We spoke to the manager about this who said it is difficult for them to do their own washing due to the needs of people in the main house. This would be made easier by the coach house having their own laundry facilities and the manager pointed out an area where this could be sited. It becomes a requirement of this inspection report that this is addressed. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 20 On the second day of the site visit the manager confirmed that a new kitchen was going to be installed in January. The communal areas of the main home were seen to be clean and hygienic (with the exception of the points highlighted above). The coach house was clean and hygienic throughout Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 21 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Training records are unclear which makes it impossible to confirm that staff training has been updated recently as required. New staff receive a comprehensive induction programme that provides them with the knowledge and skills to meet people’s needs. People are being put at unnecessary risks by the home’s failure to follow recruitment procedures. EVIDENCE: The AQAA completed by the manager showed that of a staff team totalling 16, 12 staff have completed a minimum of an NVQ (National Vocational Qualification) level 2, whilst 4 others are working towards theirs. 3 of the staff spoken with during the site visit talked about completing their NVQ and their future training plans. All of the staff spoken with said that the training available was really good. On the 2nd day of this site visit we looked at the training records for staff. The manager stated that the organisation’s head office book training when it is Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 22 required, the manager is then informed when staff need to complete the training. The manager showed us a copy of the home’s most recent training matrix. Examination of this document showed a number of irregularities where it appeared a number of staff’s training was a year out of date. The manager must review this document and provide the CSCI with an explanation for this, and where required ensure that the appropriate training is booked. This becomes a requirement of this inspection report. 2 new staff were spoken to about the recruitment process and their induction. They confirmed that they had both completed application forms, supplied references, Criminal Records Bureau disclosures had been completed and the manager had completed the induction standards with them. The personal files for 5 new staff were examined in detail. 3 of the 5 files were in order and provided all of the information required by these standards, while the other 3 must be reviewed. Shortfalls identified: • File 1. Contained only a standard disclosure from a previous employer. The same file also did not provide a full employment history. Both of these are required by the regulations. File 2. Did not have a full employment history. • The manager must ensure that these shortfalls are addressed. This becomes a requirement of this inspection report. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 23 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, 40, 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is appropriately qualified to manage the home and her leadership enables the team to meet the current needs of the people living in the home. Quality assurance is not monitored thoroughly and makes it impossible to confirm that corrective actions are taken where people living in the home identify shortfalls. Policies and procedures are updated regularly to reflect current practices and thinking. Health and safety is well managed and minimises potential risks to people living in the home. EVIDENCE: The manager has considerable experience in working with people with learning disabilities and is appropriately qualified with the Registered Manager’s Award. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 24 People spoken with during the site visits were positive about the manager and staff team stating that they felt they could talk to the manager and staff if they had any issues. As part of the inspection process we surveyed staff about the home. All of the comments were positive about the team and the support provided by the management team. Comments made by staff during the site visit further supported the completed surveys. Examination of staff meeting minutes showed that this year 2 meetings had taken place (July and October). It is a good practice recommendation that staff meetings are held more regularly. From speaking to people in the home there is evidence that people feel the service they receive meets their needs. The manager must ensure that a quality assurance system is introduced that puts the people in the home at the centre. This becomes a requirement of this inspection report. Regulation 26 visits are being completed regularly. A number of the home’s policies and procedures have been updated since the previous inspection was completed. These policies include Retirement, age and the workplace, religion and belief, medication and redundancy. In addition to this the home’s Statement of Purpose has been reviewed. The home have obtained a copy of “safer food, better business” from the Environmental Health Department. As the title implies this tool helps businesses to employ better, safer practices in food preparation. Examination of the document showed that it had not been started. It becomes a good practice recommendation of this inspection report that this is implemented. At present the staff monitor and record fridge and freezer temperatures, but a food probe is not being used. It becomes a good practice recommendation that staff use the food probe regularly. COSHH (Control of Substances Hazardous to Health) are stored securely in the home’s laundry. COSHH data sheets are available. Hot water outlets are tested and recorded monthly by staff. Fire alarms and the emergency lighting is checked by staff regularly. In addition to this they are serviced by a qualified engineer. A fire drill has been completed this year, but it would be good practice to complete a fire drill at night. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 2 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 3 X 2 X Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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(2) b, 12(1) a Requirement The manager must review people’s care plans to ensure that they are all person centred. Where possible there should be clear evidence that people living in the home are involved in their development. Timescale for action 28/03/08 2. YA7 15 The manager and staff should 01/02/08 ensure that they record their input when supporting people to make decisions about their lives. In addition to this the manager should be mindful to record all of the staff actions when supporting people to go about their lives and learn new skills. 1. Topical creams must be labelled with the date the date they are opened. This requirement is carried over from the previous inspection report. Hand written medication instructions on administration sheets must be signed by the member of staff writing them. Version 5.2 Page 27 3. YA20 13(2) 04/01/08 2. Mantley Chase DS0000049949.V344834.R01.S.doc 3. Where medication has been discontinued staff must make it clear on the medication sheet, again the staff member must sign this. 29/02/08 4. YA24 23(2) d, c The kitchen/diner must be decorated. Timescale not met 01/06/07. Requirement carried over from the previous inspection report The safety fence at the top of the main stairs must examined and any sharp edges removed so that people are not being put at risk. Above the laundry door a large piece of plaster is missing and must be replaced. The ceiling in the communal laundry is bowing and must be repaired. The coach house must have their own laundry facilities. The wooden “fence” between the kitchen and dining area must be painted as in its current unfinished state it poses a health and safety risk. The bedroom that had water damage from the upstairs flat must be redecorated. 5. YA24 13(4) a, c 01/02/08 6. YA24 23(2) b, d 15/02/08 7. YA24 23(2) b, d 15/02/08 8. 9. YA24 YA24 16(2) f 13(3), 13(4) c 28/03/08 04/01/08 10. YA25 23(2) d 14/03/08 11. YA25 23(2) d The bedroom where water 14/03/08 damage has been repaired above a curtain rail (by fire exit steps). Must now be decorated, as at present it is bare plaster. Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 28 12. YA25 23(2) d Downstairs bedroom. An area of the wall has been repaired/replastered. This must now be painted. The floor covering in the flat must be replaced. The flat at the top of the house must be redecorated. Timescale not met 01/06/07. Requirement carried over from the previous inspection report The main bathroom must be decorated and the lock on the door must be replaced. Staff must ensure that light bulbs are replaced as required. 15/02/08 13. 14. YA26 YA26 13(4), 23(2)b 23(2) d 29/02/08 28/03/08 15. YA27 23(2) b, c, d 23(2) c 23(2) b 29/02/08 16. 17. YA27 YA27 04/01/08 The doorframe to the downstairs 15/02/08 shower room is split and must be repaired. The registered manager must 01/02/08 ensure that all areas of the home are clean and hygienic. Timescale not met 23/03/07. Requirement carried over from the previous inspection report On this occasion this relates to 1 bedroom in particular that smelt of faeces. The floor covering must be replaced. Staff training records must be 01/02/08 reviewed to ensure that all staff are up-to-date with their training. The manager must then write and tell us about her findings. Staff files must be reviewed and 01/02/08 the missing information added to the files. The manager must be mindful of information required by these regulations so people DS0000049949.V344834.R01.S.doc Version 5.2 Page 29 18. YA30 13(3) 19. YA32 7, 9, 19 schedule 2 20. YA34 7, 9, 19 schedule 2 Mantley Chase are not put at unnecessary risks. 21. YA39 24 A quality assurance system must be introduced into the home. 28/03/08 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 YA6 YA18 Good Practice Recommendations Reviews of people’s needs and activities should be recorded more thoroughly and regularly. The manager should ensure that the care plans to address people’s personal care needs should be person centred and enable staff to support people consistently. The manager should implement the “safer food, better business” pack. The manager should ensure that the food probe is regularly used by staff and the results are recorded. The manager should complete a fire drill during an evening/night. 3. 4. 5. YA42 YA42 YA42 Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mantley Chase DS0000049949.V344834.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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