Inspection on 09/01/06 for Mantley Chase

This inspection was carried out on 9th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mantley Chase 29/11/07

Mantley Chase 24/01/07

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 Unannounced Inspection 9th January 2006 10:00 Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 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.V276985.R01.S.doc Version 5.1 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.V276985.R01.S.doc Version 5.1 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) Holmleigh Care Homes Ltd Mrs Mary Ann Theresa Badham Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 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 has access to transport which enables them to make use of the local and surrounding areas. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over a period of 2 hours and 45 minutes on a day in January 2006. At the time of the inspection the manager was not on duty and the inspector was supported by one of the senior staff throughout the inspection. The majority of the service users were at home at the time of this inspection and the inspector spoke to one of them, while observing interactions between service users and staff. The aims of this inspection were to assess the home’s progress towards meeting the 5 requirements of the previous inspection, and to inspect 1 of the key standards that was not assessed at that time. The inspector spoke at length to the staff on duty and examined some of the service users records. It is recommended for a more comprehensive overview of the service provided at the home this report should be read in conjunction with the previous report dated 18th August 2005. What the service does well: What has improved since the last inspection? The requirements of the previous inspection to improve the environments of some of the service users’ bedrooms and their en-suite facilities have been achieved. Service users contracts are now appropriately signed. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 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.V276985.R01.S.doc Version 5.1 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): 5 Service users’ rights are protected by the use of contracts that identify the each party’s responsibilities. EVIDENCE: At the previous inspection a shortfall was identified with the service users’ contracts. Examination of a sample of these documents showed that some had not been signed by the service user or their representatives. The sample seen on this occasion had been signed by service users’ representatives and therefore meets the criteria of the standards/regulations. At the previous inspection key standard 2 was not assessed as no new service users had moved into to the home since the previous inspection. This was the same case at this inspection. New service users are expected to be admitted to the home in the coming months and at this point the inspector will be able to assess the home’s practices against the criteria of standard 2. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 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 the following standard(s): 7 Restrictions to service users freedom and choice must be documented and kept under review to ensure that restrictions are really necessary. EVIDENCE: At the previous inspection standards 6, 7, 9 and 10 were assessed and found to meet the required standard. Whilst the inspector was completing the tour of the premises he identified a couple of issues about restrictions to service users freedom. This mainly related to the practice of service users cupboards and wardrobes being locked. The inspector could not find documentation to support this practice and spoke to the senior support worker about the importance of these documents being in place. If the home is restricting a service user’s choice/freedom then the reasons must be documented and kept under review. The inspector suggested that in addition to the areas identified that each of the service users are assessed. This becomes a requirement of this report. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 10 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): 17 The meals provided to the service users are wholesome and nutritious providing a healthy diet. EVIDENCE: At the previous inspection standards 12 to 17 were assessed and found to meet the required standard. At this inspection the inspector examined the menus available in the home’s kitchen. Menus seen work on the basis of a 4-week rota which is reviewed with the different seasons throughout the year. The meals available were seen to provide the service users with a good range of wholesome, nutritious food supporting a healthy diet. The inspector spoke to staff about service users choice, and if they did not want what was on the menu were other choices available? Staff explained that if a person wanted something else then this was possible and staff would prepare it. The staff must ensure that where this is the case that it is recorded in a person’s notes. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Practices should be reviewed to ensure that service users’ privacy and dignity are being respected at all times. EVIDENCE: At the previous inspection standards 18, 19 and 20 were inspected and found to meet the required standard. The inspector spoke to the staff member about service users privacy, and how this is respected. The staff member spoke about supporting a service user to have a bath, and that for the service user’s safety they stay in the bathroom with them. The inspector asked whether this was necessary, and whether they could in fact sit outside the bathroom therefore allowing the service user privacy. The staff member stated that they felt the best option was to stay in the bathroom to ensure a safe environment. It is a recommendation of this report that practices such as this are reviewed to ensure that they are still appropriate. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: Both of these standards were inspected at the previous inspection and found to meet the required standard. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 13 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, 29, 30 The home is decorated to a good standard throughout and provides service users with a comfortable homely environment. The home provides the service users with more than sufficient communal space to meet their current needs. EVIDENCE: A tour of the premises was completed and the progress towards meeting the requirements of the previous inspection were assessed. Inspection of the 3 bedrooms to which the requirements related showed that they had all been addressed. A recommendation for one service user’s bedroom (P’s bedroom) would be to install mirrored film to the outside of their windows due to them pulling the curtains down regularly. This measure would ensure that their privacy and dignity was respected at all times, as they would not be able to be seen from the outside of the home. Communal areas were visited and seen to be decorated to a good standard providing the service users with a range of furniture and more than ample space. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 14 Bathrooms and toilets were seen. The inspector noted that the lock on the upstairs bathroom did not work and this must be addressed and becomes a requirement of this report. The inspector noted that some of the lampshades were missing and the staff explained that the manager had ordered some new ones. The home has a large conservatory at the rear of the building which the proprietor has decorated. The furniture currently in the room is not to the standard of other furniture around the home and should be replaced. This becomes a recommendation of this report. All of the areas seen by the inspector were clean, tidy and free from offensive odours. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 15 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): 35 The home offers staff training in mandatory topics required by these regulations as well as training to meet the specific needs of the service users. This supports the staff to provide a needs led service and safe environment. EVIDENCE: At the previous inspection standards 31, 32, 34 and 36 were inspected. 1 of the key standards (35) was not inspected at the previous inspection. The inspector examined the training programme for January to March ’06. This showed that courses in the following subjects had been organised: recognising and responding to abuse, total communication, fire awareness, supervision and appraisal and continence promotion. Records showed that between 2 and 5 staff were completing each of these courses. As the manager was not present the inspector was unable to assess the courses that had been completed since the previous inspection. The inspector will assess these records at the next inspection; the inspector was unable to score this standard, as they were unable to inspect it fully. At the previous inspection the inspector identified a shortfall in a new staff member’s file. As the manager was not present at this inspection the inspector Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 16 was unable to access these records and could not confirm whether this has been addressed. This will be examined at the next inspection. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 17 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): 42 A safe environment for the service users is maintained through the regular servicing of equipment by appropriately qualified personnel. Regular monitoring of the fridge and freezer temperatures contributes to minimising the risks to the service users of food poisoning. EVIDENCE: At the previous inspection standards 37, 38, 39, 40 and 42 were assessed and judged to have met the required standard. At this inspection the inspector noted that: Portable appliance testing had been completed in June ‘05 Fire extinguishers had been tested in April ‘05 The fire alarm panel had been serviced in October ‘05 Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 18 A shortfall identified at this inspection was the recording of the fridge/freezer temperatures. Staff on duty explained that this had been the responsibility of a staff member who had recently left. The records seen by the inspector confirmed that up until recently the recording was completed regularly. The staff member explained that another staff member had been given the responsibility for completing this task in future. The inspector will examine these records again at the next inspection. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 19 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X X X X X X X X 2 X Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 20 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 YA7 Regulation 12 (2) Requirement Timescale for action 03/03/06 2. YA27 23(2) c The manager must ensure that any restriction to a service users choice or freedom is documented with the reasons for the restriction. These restrictions must be kept under review. The manager must ensure that 03/02/06 the lock on the bathroom doors is replaced. 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. 3. 4. 5. Refer to Standard YA4 YA7 YA18 YA24 YA26 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. The manager should review procedures to ensure that service users privacy and dignity are respected. The manager should ensure that the furniture in the conservatory is replaced. The inspector recommends that the mirrored film be fitted DS0000049949.V276985.R01.S.doc Version 5.1 Page 21 Mantley Chase 6. YA42 to the bedroom window as described in the body of this report. The manager should ensure that fridge and freezer temperatures are recorded regularly. Mantley Chase DS0000049949.V276985.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Gloucester Office Unit 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 DS0000049949.V276985.R01.S.doc Version 5.1 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. 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