Inspection on 23/11/06 for Marian House

This inspection was carried out on 23rd November 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marian House 23/11/05

Marian House 31/01/05

Marian House 10/09/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Marian House 803 Chester Road Erdington Birmingham West Midlands B24 0BX Lead Inspector Jennifer Beddows Key Unannounced Inspection 23rd November 2006 09:00 Marian House DS0000016972.V314876.R02.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 Marian House DS0000016972.V314876.R02.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. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marian House Address 803 Chester Road Erdington Birmingham West Midlands B24 0BX 0121 373 6140 F/P 0121 373 6140 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) Mrs Annette Keogh Mr Thomas Keogh, Mrs Margaret Keogh Mrs Sharon Stirland Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Residents must be aged under 65 years with a learning disability. The home can continue to accommodate 6 named service users over the age of 65 years. That Marian House apply for a variation on behalf of other service users who reach the age of 65 years That details regarding how the specific care and social needs of those people over the age of 65 years will be met, must be include in the service users plan. The statement of purpose must be amended to reflect the age of the service uses accommodated. 23rd November 2005 Date of last inspection Brief Description of the Service: Marion House is a large three storey Victorian House situated close to Erdington, and has been established since 1980. It currently offers a service to residents with a learning disability. The home has eleven single bedrooms and three double bedrooms. There is one lounge, a dining room and two kitchens. There is ample room for parking on the front driveway and access to the building is via a ramp providing wheelchair access. The large gardens to the rear are well maintained. Local amenities such as shops, banks and GP practice are close by with good transport connections via bus and rail services. There are adapted bathing facilities on the ground floor and a stair lift for access to the first floor bedrooms. The home provides 3 meals a day and is staffed on a 24-hour basis. Fees £380-£1158 Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced and took place over one day. The home had reached its capacity and there are no vacancies. Many residents were at home on the day of the inspection and were able to express their views regarding their experience of the home. Residents care plans and records were inspected including those who had recently moved into the home. Also members of staff were spoken to and their working practice with the residents was observed. The recruitment and training records of two members of staff were inspected and a tour of the premises took place. There were also discussions with the registered manager and the proprietor. A pre-inspection questionnaire was provided by the home, and surveys were also received from the General Practitioner, relatives and most of the residents. The comments from these were positive. What the service does well: The home supports the residents to participate in group projects once a year such as pantomimes and shows. All residents take part to produce and perform for members of the local community. At the time of the fieldwork residents were keen to show the inspectors their specific costumes and residents were excited about their forthcoming performance. This gave the residents a valued role in their local community as the public came to watch the show and show their appreciation. It also promoted a sense of co-operation between residents as they were working together toward a common goal. The home engages residents to participate in the general running of the home and encourages their contribution and opinions. Those residents spoken to stated their opinions were valued, and they felt supported. At the time of the fieldwork residents were keen to show the inspectors round and had considerable knowledge regarding the functioning of the home, not only in relation to themselves, but also with regard to its overall aims and policies. The home makes comprehensive assessments of its residents in many aspects of their lives in order to promote their interest and well being. These included their cultural and religious needs and it was apparent where possible the individual had been included in the development of their plan of care. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 6 The home has a commitment to training its staff in order to meet the specific needs of its residents. Staff interviewed showed a commitment to and knowledge of the residents group. The home encourages residents to personalise their rooms and provides them with their own key to promote their privacy and independence. The home encourages its residents to have regular annual holidays. What has improved since the last inspection? What they could do better: The home needs to ensure there is sufficient seating in the dining room and lounge for all the residents. Health care support and the administration of medicine need to be improved. The home needs to identify the changing needs of its older residents, and their specific age related health and social needs to be incorporated into their care plans. Critical tests were not evidenced, such as Portable Electrical Appliance (PAT) certificate, fire alarm and gas safety certificate. Also risk assessments for the premises such as food and infection control need to be evidenced and reviewed. There needs to be greater development to evidence how specific risks had been assessed with regard to its residents, and the control measures put in place to better manage them thereby promoting residents health and safety. The home needs to ensure gaps in employment history are explored and recorded to ensure that its recruitment policy is supportive of its residents. The home needs to keep fuller notes regarding supervision of staff to demonstrate it is supportive in developing their roles in order to better meet the specific needs of its residents. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 7 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. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 8 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 Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 9 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): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Prospective residents individual needs and aspirations are assessed and they are encouraged to have over night stays prior to being admitted into the home. EVIDENCE: From the residents records inspected, appropriate information had been provided to prospective residents in order for them to make informed choices regarding moving into the home. Although pre-admission assessments had been carried out by the social worker, the home had developed its own comprehensive assessment process. The records of the most recent resident to move into the home was sampled, and good information regarding their social habits had been obtained that included preferred places when going out, as well as preferences, religious and family contacts. Monthly key worker sessions had taken place since admission to obtain feedback from the resident to review their experience of the home. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 10 There had been a slow introduction to the home prior to the admission by offering this resident over night stays. This provided opportunity for the resident to experience the home before moving in. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Residents are involved in regular reviews, which reflect their personal goals and changing needs. However the home has not assessed the changing social and health needs of those residents over the age of 65 years. EVIDENCE: Each service user had an individual plan of care, which was generally very focussed on their needs, wishes, likes and dislikes. It was apparent where possible the individual had been included in the development of the plan. It is a Requirement that each file has the residents photograph, as this would help new staff to identify residents more easily. It was positive to find many examples of service users involved in the planning and organising of their own lives, their care and the home. This included being involved in care planning, choosing activities and holidays, and participating in the choice of décor for the redecoration of the home. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 12 There is a kitchen, freely accessible to service users, where they can make drinks and snacks. On the residents files, were completed questionnaires showing the manager had canvassed opinion about staff support, food, and the activities. However it was difficult to track how this information had been analysed, and incorporated into practice. This process needs to be evidenced to ensure the resident is receiving a personalised individual service. It would be positive to see some of this work further developed to support residents towards greater independence such as being able to prepare full meals, and where appropriate being supported with self-administration of medication. This may include residents holding their own records and these being developed in a format they can access. It was positive that the plans included information about culture and religion, and how or if someone wished to be supported in this area. Risk assessments were available in the files sampled. These needed greater development to evidence how the risks had been assessed, and the control measures in place to minimise the level of risk involved, thereby promoting the residents health and safety. The social and health care needs of those residents over 65 years of age have been dealt with in standard 21. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Residents have opportunities for personal development and can take part in community activities appropriate to their age and peer group. The home is supportive of residents family relationships. Weekly menus show a wide range of wholesome food is offered to the residents in order to meet their daily requirements. EVIDENCE: The home provides support and encourages its’ residents to produce annual plays in the local school, and invites members of the community to watch their performance. This enables the residents to develop their confidence and communication skills and provides them with opportunities for personal development. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 14 As this is an annual event it demonstrates that the home is also making consistent efforts to take an active role in maintaining neighbourly relationships between the residents and the local community. Residents may benefit from greater social inclusion by enrolling in a local drama group in order to mix with a wider range of people from the community. Residents are encouraged to participate in adult education courses by attending the local college. One resident proudly showed his education certificates on his bedroom wall, and another said that staff had assisted him to obtain voluntary work at the local betting shop, which he enjoyed. This enables residents to not only take part in valued and fulfilling activities, but also encourages their participation in the local community. Residents records show that family and friends are encouraged to visit the home, and have family contact. Arrangements are in place to maintain appropriate family relationships. Residents also stated that they had made friends at college. The residents spoken to said that they had keys to their own bedrooms, and that staff respected their privacy by knocking on their door and waiting to be invited in. This was observed during the fieldwork. Staff were observed to relate in a friendly inclusive manner with residents, who seemed comfortable and at ease with them. Residents were also keen to show inspectors around the building, and made positive comments about living in the home. From the records observed, the home promotes the residents health and well being by providing a range of healthy foods with a choice of menus. The meal provided on the day of the fieldwork offered residents choices and was nutritious and wholesome. Mealtime was relaxed and unrushed and ample food was provided allowing residents second and third helpings. Residents were encouraged to eat their meal in smaller groups, and some chose to have their meal in the television room away from the main group. However there were not enough chairs in the dining room to seat all seventeen residents in one sitting should this have been the residents choice. Residents also assisted staff to carry the food to the dining room and were encouraged to have a useful role, by serving the meal to everyone. However staff did not make themselves available to the residents throughout the meal, and were unavailable for the larger part of it, as they did not sit down with the residents group and eat with them. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 15 Consequently the limited seating facilities in the dining room may have a bearing on the options that ought to be made available to the residents at meal times, namely to eat with staff and as one large group, if they so choose. The current resource that the home makes available to its residents does not appear to allow residents to make these choices. It is therefore a Requirement that the registered manager regularly reviews the choices residents appear to be making regarding seating at mealtimes, and by providing additional seating in the dining area, it will allow them a daily choice as to where they would like to sit. It is recommended that staff sit with residents at mealtimes to model good practice and to promote positive interactions at lunch times. One resident spoke of healthy eating and that he was pleased he had been supported by staff to reduce his calorie intake and to lose weight. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 and 21 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to the service. Systems to manage the administration of medication were not robust and could result in an error in administration. The management of specific health needs such as epilepsy and diabetes need to be identified in order to promote the residents safety. Some of the people accommodated over the age of 65 years have not had their health and social care needs incorporated into their care plans, which is in breach of the Care Standards Act 2000 . EVIDENCE: Those residents observed on the day of the fieldwork were dressed in a style that reflected their age, gender, interests and culture and it was apparent they had been supported with personal hygiene that day. It is recommended that the use of stock towels and bedding be reviewed, and that residents hold their own supply in their rooms. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 17 Overall the recording that was sampled in residents files was good. Staff had personalised their recording and it was detailed, however health care records were not current. One resident stated he was aware of his personal plan and that the manager and his key worker had read it through with him. He expressed satisfaction with his care plan. The residents accommodated have a wide range of health needs. It was not possible to track that all residents had been offered appointments with the dentist, optician, GP or that all specific health care needs were well met. It was positive that since the last inspection the residents and staff had been developing Health Action Plans. It is recommended where possible these be held by the resident, and they be presented in a format they can access. Specific health needs such as epilepsy; diabetes and mobility need to be underpinned with specific plans, to evidence how these needs are met. It was positive that where necessary residents had been supported to gain or loose weight. However this should be undertaken within a framework, identifying healthy goals, with clear objectives as to how this will be achieved. Some of the people accommodated are over the age of 65 and it had previously been agreed that these individuals could continue to receive a service from Marion House, as long as their specific age related health and social needs are incorporated into the plan of care. This had not been undertaken, which constitutes an offence under the Care Standards Act 2000. The manager agreed to rectify this with urgency. In practical terms, the home has responded appropriately to one of these residents who is becoming frailer and less mobile. In order to meet his changing needs the home is refurbishing an empty room on the ground floor into a bedroom with en suite facilities in order that he can be more comfortable Medication management was poor, and it was not evident that all residents were receiving the right medication at the right time. The system to underpin medication administration was not robust, and could result in an error in administration occurring. The manager must ensure that a full audit of medication received into the home is undertaken and recorded, prior to medication being administered. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 18 Medication prescribed on an “ As Required” (PRN) basis and any home remedies, must be underpinned with a protocol, detailing when it is to be given, and the dose. Staff must write in full directions for administration in the event of a printed medication administration record (MAR) chart not being available. Creams must be dated when opened, and used or discarded within 28 days. All residents must have a photograph on their medical files, to ensure easy identification with regard to being given the correct medication. . Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Residents can be confident their views are listened to and they are protected from abuse and self harm. EVIDENCE: Since the last inspection, no complaints have been received by the home, or by the Commission. The complaint policy was generally good, but needs to be developed further to inform the reader how the complaint will be investigated and in what timescale. It would benefit the residents if they were provided with a copy to keep in their rooms. There was clear information posted around the home inviting residents to comment if they were unhappy, but it wasn’t made clear how a complaint would be investigated or the time scales involved. It is a Requirement the home makes the process of its complaint procedure known to all residents, relatives and professionals, in order that people can be aware of how to raise any issues. From the records sampled, it was encouraging to see a complaint leaflet had been translated into Makaton for easy reading. Two members of staff were spoken to regarding their understanding of how to protect vulnerable adults. One member of staff said they would not hesitate to Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 20 protect a resident should the need arise and was able to explain the “whistle blowing policy”. Another said they would make management aware of an abusive situation straight away. The homes adult protection policies are based on the Birmingham Multi-Agency Adult Protection Procedures, which it uses for guidance on how to respond to allegations of abuse. The home enables residents meetings where the residents are able to raise issues and complaints. The minutes of these meetings reflect active involvement on the residents part. The majority of the residents pre-inspection recorded comments stated they were aware how to make a complaint and the preferred method would be via their key worker. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The residents live in a homely, comfortable and safe environment, which is clean and well decorated. Residents bedrooms are spacious and personalised to suit their own lifestyle. All residents have their own key giving them privacy and independence. EVIDENCE: All rooms observed during the fieldwork were clean, tidy, comfortable and fresh. These included residents’ bedrooms as well as shared areas in the home such as communal bathrooms and living areas. Furnishings and fittings were of good quality and fit for purpose. Those residents spoken to expressed satisfaction with their accommodation. The cover to the fuse box on the first floor had come off leaving the fuses exposed. It is a Requirement that the registered person has this repaired. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 22 Residents’ bedrooms were large and were personalised to individuals’ tastes and preference, which included cd players, stereos and computers. All were adequately stocked with residents’ personal toiletries. It is recommended that as the bedrooms are so large, residents could be given the option of having a double instead of a single bed to sleep in, thereby giving them more choice. It is a Requirement that the restriction on a residents bedroom window that had been over ridden, needs to be repaired in order to promote his safety. The lighting in some of the bedrooms is very dim, and needs to be improved in order that residents can make better use of their rooms. It is encouraging to see that the home provides residents with their own bedroom key in order to afford them independence and privacy. It is a Requirement that fire doors do not impede on privacy or evacuation in event of an emergency, and meet with West Midland Fire Service regulations. The call bell system was working in the rooms inspected and staff responded in a reasonable time. There was evidence that the owners were trying to adapt the premises as service users needs change by the inclusion of ramps and ground floor rooms. Some aspects of the homes design are not ideal for their purpose, such as the distance from the kitchen, to the dining room, and having to go through the kitchen to the staff office at the back of the home. Also soiled linen needs to be transported to the laundry through food preparation areas. While it is appreciated these cannot be changed, the registered person needs to provide risk assessments and clear working procedures to minimise the risks presented. It is positive that a ground floor room had been converted to provide a bedroom and ensuite accommodation for an existing resident, but it was not evident how adequate seating in the lounge or dining space was being provided for the 17 people accommodated. It is a requirement of the inspection that the providers produce an action plan regarding this. There is a need to ensure all hot water is delivered at an acceptable temperature. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 23 The home provides two kitchens, one for residents to make hot drinks and snacks. Both kitchens were well stocked with ample supplies of food and drinks. It is a Requirement that the registered person provides separate hand washing facilities in this kitchen, so that residents do not have to wash their hands in the kitchen sink when preparing food. The home had posted many leaflets about the building for the residents and staffs information. These included a development board listing all the planned activities for individual residents that week. Clear information was provided regarding the dates when the aroma therapist called as well as the activities worker, who both visit the home on a weekly basis. The large hall on the ground floor has been turned into a smoking area. The rear garden is large and well maintained and residents have access to use this facility in the warmer weather. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 24 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): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Residents are supported by competent and qualified staff, who showed commitment toward the residents group. Feedback from residents was entirely positive. The systems in place to recruit staff are adequate but need to be applied more rigorously to ensure gaps in employment history are accounted for. The recording in staff supervision notes needs to be more in depth to evidence development of their roles. EVIDENCE: The evidence from staffing rotas and staff files show the home employs an effective team to support residents assessed needs. It was evident that a significant investment had been made in training staff, and all mandatory training had been provided. The homes training matrix showed all staff have achieved the National Vocational Qualification (NVQ) level 2 in Care. This qualification is a national requirement to ensure that appropriately qualified staff care for the residents. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 25 There is a need to ensure that staff are also provided with the Learning Disability Assessment Framework induction training, in order for them to meet the residents specific needs. Two members of staff were interviewed, and showed a great commitment to the people they support and knowledge of their needs. Feedback from residents regarding staff was entirely positive, and some very positive and supportive interactions were noted throughout the fieldwork visit. Some staff members were long serving, and had worked at the home for several years. This gave the residents an opportunity to become familiar with staff, and provided them with consistency in their relationships. Records sampled showed staff had been inducted and supervision had taken place on a monthly basis. However it was not easy to track that areas of development in staff practice had been covered during supervision, because the recording in these files were sparse. It is a Requirement that the home keeps fuller supervision records in order to demonstrate it is supporting its staff to develop their roles. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to the service. It was observed the management style created an open and positive atmosphere for the residents. Residents views are canvassed in order that they are reflected in the development of the homes services. However the outcome of these views need to be analysed into an action plan to ensure they accurately underpin the development of the service. Evidence promoting the health safety and welfare of the residents was not readily available such as risk assessments regarding food hygiene, infection control and fire. Evidence that critical tests had not been undertaken such as hot water deliver, bathing equipment, fire alarms, gas safety certificate and portable electrical appliances certificates. EVIDENCE: Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 27 The manager of the home is a qualified competent person, and has achieved her National Vocational Qualification (NVQ) in the management of care services. Records suggest she has also continued to update her knowledge and skills. It was observed her management approach created an open and positive atmosphere for the residents. She was observed to relate positively toward residents and staff and residents were observed to speak openly to inspectors in front of the manager and they seemed well versed in aspects regarding the running of the home. The home’s quality assurance system seeks the views of residents, but the outcome of these surveys needs to be analysed and developed into an action plan to ensure service development. It was however positive that a dedicated person regularly undertakes checks of the environment to include ramps etc. to ensure residents live in a well maintained home. From the records observed residents comments had been positive regarding their experiences of the home, some of whom had been provided with advocates in order to express their views more affectively. Some critical tests had not been undertaken, or could not be evidenced to include the hot water delivery, bathing equipment, fire alarm, gas safety certificate and Portable Electrical Appliances (PAT). It is a Requirement that the home sends current certificates regarding these to the Commission. A cleaning rota is in place, and the home environment seemed clean and fresh. Risk assessments for the premises, food, infection control and a more detailed risk assessment for fire need to be completed. These documents must be dated and signed and include evidence of periodic and required review. The home is arranging for a new fire door retaining system to be fitted, which will replace the current practice of wedging open doors, which is unacceptable. There is a need to review with the West Midland Fire Service the use of locks with keys on doors designated as fire escapes. Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 28 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 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 1 2 x 2 x x 1 x Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 17 Requirement The registered person must provide a photograph of residents on their personal file and on their medication chart. The registered person must review all residents health care plans and identify individual medical conditions giving clear guidance to staff as to how to best monitor them. The registered person must put in place appropriate systems for the receipt and the disposal of residents medication and ensure proper records are kept for their administration. There is also a requirement that proper protocols must be developed for “as required” and home remedy medication The registered person must provide a copy of the complaints procedure to the residents. The registered person must identify the social and health needs of those residents 65 years and over and incorporate in their care plans Timescale for action 14/01/07 2. YA19 12 (a) 14/01/07 3. YA20 13(2) 14/01/07 4. 5. YA22 YA21 22(5) 15(1) 21/01/07 21/01/07 Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 30 6. YA24 23(g) 7. YA24 13(4) (a) 8. YA24 23(2) (P) 9. YA24 24(4)(b) 10. YA30 13(3) 11. YA34 18 1(A) 12. YA36 18(1)(2) 13. YA42 13(4)(c) The registered person must ensure there is adequate seating available in the lounge and the dining room for all the residents. The registered person must make arrangements for the fuse box to be repaired on the first floor. The registered person must ensure that adequate lighting is provided in all of the residents bedrooms. The registered person must review all lockable fire doors with West Midland Fire Service and produce evidence of this assessment to the Commission. The registered person must provide risk assessments to enable clear working procedures regarding laundry being carried through food preparation areas, and the absence of hand washing facilities in the residents kitchen in order to minimise the risks involved. The registered person must develop the homes recruitment policy to ensure gaps in applicants employment history are accounted for and their identification verified. The registered person must evidence the supervision of staff involves the development of their roles The registered person must provide the Commission with current certificates regarding the portable electrical appliances, bathing equipment, fire alarms and gas certificates. 21/01/07 21/01/07 28/01/07 28/01/07 28/01/07 28/01/07 28/01/07 07/01/07 Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 31 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. Refer to Standard YA11 Good Practice Recommendations It is recommended the home where possible supports its residents to be more independent such as preparing full meals, self- administration of medication, holding their own records. It is recommended that staff sit with residents at meal times to model good practice and to promote positive interactions at lunch times. It is recommended residents keep their own supply of towels and bedding in their rooms. It is recommended that all staff receive Learning Disability Assessment Framework training. 2. 3. 4. YA17 YA18 YA32 Marian House DS0000016972.V314876.R02.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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