Inspection on 27/06/06 for Marion House

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marion House 11/07/08

Marion House 26/07/07

Marion House 24/01/06

Marion House 20/06/05

Marion House 09/11/04

Marion House 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Marion House 40 The Avenue Moordown Bournemouth Dorset BH9 2UW Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 27th June 2006 09:30 DS0000003961.V301891.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 DS0000003961.V301891.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. DS0000003961.V301891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marion House Address 40 The Avenue Moordown Bournemouth Dorset BH9 2UW 01202 521985 01202 519002 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) Prospects for People with Learning Disabilities Mr Franco Monteregge Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000003961.V301891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Marion House is a large detached house in a quiet residential district of Bournemouth known as Moordown. The local area includes a wide range of shops, churches and community services, and is served by local bus services. The home accommodates up to eight adults of both sexes who have learning disabilities and some additional disabilities such as visual impairment. Each resident has their own bedroom, seven are on the first floor and the eighth on the ground floor. A Day Opportunities service is attached to the property but is separated from the care home by a locked door and has its own entrance at the rear of the property. The home comprises of a lounge, a dining room, a quiet room, a laundry and a kitchen. There are three bathrooms with toilets, three shower rooms with toilets, and two other separate toilets. Outside there are attractive grounds that include a fountain, sensory garden and pergola. The home is staffed 24 hours a day and there is a designated key worker and support key worker for each service user. The home is a part of the PROSPECTS organisation and the registered provider is the Chief Executive of that organisation, based at the Head Office in Reading, Berkshire. PROSPECTS has been involved in the support of people with learning disabilities since 1975 and operates various services across the U.K. It is an organisation rooted in Christian principles and the ethos of the home reflects this. There is however no requirement for anyone to engage in religious activity whilst they are supported by PROSPECTS. DS0000003961.V301891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place over approximately 7 hours. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. This inspection was a key inspection and therefore, assessed all identified key national minimum standards for care homes for adults (18-65). The inspector initially spent time with the team leader of the home and examined various records and documentation including care plans, risk assessments, staffing records and health and safety records. The inspector conducted a tour of the premises viewing all communal areas of the home and a sample of 4 service users’ bedrooms. The inspector also had the opportunity to speak with five residents who spoke positively about their experiences of living in the home including their rooms, their weekly activities, the staff and the food. One service user summed it up by saying “I like everything.” Additional information received by the inspector prior to the inspection was also taken into account. This included 6 service user surveys, 3 relative surveys and 3 professional surveys and any other information such as monthly monitoring visit reports from the responsible individual of the home. Relatives and professionals made positive comments about the home including “Marion House gives excellent care and support” and “I am always very impressed with the standard of care, commitment and dedication staff at Marion House provide”. One relative commented, “Extra staff at weekends would be a bonus.” What the service does well: Marion House has a Christian ethos that places a high importance on creating a caring environment where service users are treated with dignity and respect. Care planning systems are very effective, person centred and provide for good participation by service users. Care plans ensure staff have a very good understanding of service users personal care and health care needs with detailed recording of daily routines promoting consistency of care and service user choice. Service users lead active lives with many opportunities to undertake a variety of social, educational and leisure pursuits. There are excellent links to the local community and service users are supported to maintain friendships and family relationships outside the home. The home has a committed and enthusiastic staff team and rotas showed the numbers and skill mix of staff on duty ensure the home is well run and DS0000003961.V301891.R01.S.doc Version 5.2 Page 6 organised, supporting the assessed needs of service users at all times. Observation of practice showed that staff were accessible to service users and fully interacted with them during the inspection. There is a strong commitment to training and the inspector noted that as well as the required courses ensuring safe working practices the home promotes additional courses that reflect the home’s aims and service users needs such as epilepsy, dementia and challenging behaviour. Marion House is attractively decorated and comfortably furnished providing a homely setting for service users to live in. What has improved since the last inspection? What they could do better: There has been some inconsistency in the management of the home with the registered manager being off due to long term sickness. The team leader has been managing the home in the manager’s absence but there needs to be some clarification of leadership roles and responsibilities to ensure the home continues to be run effectively. The inspector noted that the service users personal allowance money appears to be going directly from their bank accounts to Prospects business accounts. This does not comply with the regulations as service users personal money should not be paid into the organisations account. Service users should be able to access their personal money direct from their bank accounts and this needs to be addressed. DS0000003961.V301891.R01.S.doc Version 5.2 Page 7 Improvements need to be made to the way in which the home deals with complaints. The inspector found there had been some confusion amongst the staff team about what constitutes a complaint and on one occasion an incident in the home had been logged incorrectly as a complaint. This meant that CSCI had not been notified about the incident as required when a service users wellbeing or safety is adversely affected. The current system of logging complaints does not comply with the Data Protection Act and only one complaint should be logged per page to maintain confidentiality. The inspector felt training in this area would improve the way complaints were managed in the home. A breach in recruitment procedures was found; the inspector noted that a member of staff’s work permit had expired. This was brought to the team leaders attention and an immediate requirement was issued for the home to resolve this issue. An annual development plan needs to be made available to CSCI with evidence that feedback has been obtained from service users and this has been incorporated into the plan. This would provide action points/targets to further improve the quality of service in the home. The systems for risk assessment and management need to improve to ensure that staff are clear about risk to service users and how these are to be minimised. Although there was evidence that service users independence in daily living tasks was encouraged such as cleaning, laundry and shopping, there was a lack of opportunity for service user to cook and prepare their own meals. 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. DS0000003961.V301891.R01.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 DS0000003961.V301891.R01.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure thorough assessments of prospective service users’ needs take place in consultation with other professionals to be sure that the home will be able to meet the needs and aspirations of prospective service users. EVIDENCE: The home currently has one vacancy and a prospective service user has been assessed for this placement. This is a service user who is currently being living in supported accommodation but needs more care due to deteriorating health issues. The service user is well known to the staff and residents at Marion House. The team leader told the inspector that the social worker had completed an up-to-date assessment of the service users needs, although the paperwork was still held at his current placement. The manager also said that multi-disciplinary meetings had been held with health professionals to further discuss this service users needs. There is a policy and procedure in place that clearly sets out the homes admission procedure. Local authorities fund all service users living in the home and case tracking showed assessments were provided prior to their admission to ensure their needs could be met. DS0000003961.V301891.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning systems are very effective, person centred and provide for good participation by service users, with staff having good clear guidance on how to meet the individual’s needs and goals. Practice in the home ensures service users are facilitated to make decisions about their lives and individual choice is promoted. The systems for risk assessment and management need to improve to ensure that staff are clear about risk to service users and how these are to be minimised. EVIDENCE: Each service user has a care file named “All About Me” which they keep in their rooms. A sample of two resident’s files was examined as part of the inspection. These files contain information about the service user’s likes, DS0000003961.V301891.R01.S.doc Version 5.2 Page 11 dislikes, goals, daily routines, personal and health care needs. For example “I clean my room and do not need to be reminded or like to be reminded” and “I like to choose whether to have breakfast or get dressed first”. Each service user also has a detailed Essential Life Plan which is more descriptive and details the service user’s needs and how staff can best meet these. Service users have regular monthly keyworker meetings that are recorded when they are consulted about their plan so any necessary changes can be made. There was evidence that consultation extends to other areas of living in the home. Regular residents meetings are held where service users have the opportunities to discuss activities, food, decoration/furnishings and holidays. Discussion with residents confirmed they are able to make decisions about their daily lives and one service user told the inspector how they had recently taken the opportunity to move to a different bedroom after a vacancy had occurred in the home. They had been able to re-decorate the room and confirmed they had been able to choose the colour. Observation of practice showed service user were offered choices by staff. For example choice of evening meal and deciding whether to spend time in the communal areas or in the privacy of their rooms. Service users are encouraged to access advocacy services and several residents have independent advocates. They are also involved in 2 local advocacy groups and a regional advocacy group facilitated by PROSPECTS. It was recommended at the last inspection that risk assessments were reviewed at regular intervals. The home has a separate file where risk assessments are kept and examination of this file showed that some progress had been made in updating assessments. However, the file needs reorganising so that individual risk assessments relating to each service users are clearly filed for ease of reference. Any gaps in assessments will then be able to be identified and additional assessments completed as necessary. DS0000003961.V301891.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 this service. Service users have good social, educational and leisure opportunities and their lives are enriched by excellent links with the local community. The home has good links with family and friends and service users are supported to maintain their personal relationships. Service users’ rights and responsibilities are respected and promoted ensuring residents are encouraged to fully participate and contribute to the daily running of the home. The meals in the home are good offering both choice and variety. Creating more opportunities for service users to participate in meal preparations would further promote their personal development and independence. DS0000003961.V301891.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users daily activities are recorded on their personal files. All the service users attend the day service run by Prospects that is attached to Marion House. Activities are varied according to individual need such as work experience, social skills/community awareness, swimming, gardening, music and craft sessions. Some service users also choose to spend time in the home during the week so they can undertake domestic tasks and carry out personal shopping. Discussion with service users confirmed they enjoyed their weekly activities. They also told the inspector they regularly accessed the community visiting local shops, cafes and going for walks. Service users are also supported to attend the church of their choice. Family details are recorded on service users files and contact arrangements specified such as “can use the telephone without help, X likes to call his mother”. All service users confirmed they are supported to see their families and said they were able to have visitors to the home. There are clear guidelines about service users role and responsibilities in the home’s Service User Guide. Individual’s abilities to participate in various activities are recorded on their personal files. Observation during the inspection showed service user taking part in activities such as making drinks, laying the table and vacuuming the communal areas of the home. Discussion with residents showed that independent skills were promoted such as cleaning their own bedrooms and helping in the kitchen. A sample of menus was viewed as part of the inspection. This showed service users have a balanced diet with varied choices promoting healthy eating. Service users told the inspector they enjoyed the food in the home. They said they were encouraged to make drinks and their lunches, although there was less opportunity to participate in meal preparations as these were mainly done by staff. The team leader told the inspector she was working with staff towards more promotion of independence in the home. DS0000003961.V301891.R01.S.doc Version 5.2 Page 14 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a very good understanding of service users personal care needs and detailed recording of daily routines promotes consistency ensuring service users dignity, choice and privacy are respected. The healthcare needs of service users are well met with evidence of good multi disciplinary work taking place on a regular basis. The systems for the administration of medication are mainly satisfactory with clear and comprehensive arrangements in place to ensure service users medication needs are met. EVIDENCE: The individual resident’s files that were seen showed daily routines were recorded in detail, giving staff clear instructions about how to meet service users personal care needs. Records showed that service users are encouraged to be as independent as possible and their personal preferences are respected. For example plans state “I like to do things for myself, I do not like them being DS0000003961.V301891.R01.S.doc Version 5.2 Page 15 done for me” and “I need support to run a bath, I like to choose when to have it.” Discussion with service users confirmed they go and buy their own clothes and personal shopping. The team leader also said that individual “development days” had been set up for residents once a month when they can have 1-1 support from their keyworker to go shopping. Service users health needs are clearly recorded on their individual files. There had been improvements to the recording of appointments since the last inspection and all visits to health care professionals such as dentists, opticians and psychiatrist are now recorded on individual files as well as the home’s medication file. Observation of practice confirmed health issues were taken seriously in the home and on the day of the inspection a speech and language therapist was visiting the home to make an assessment of a service user’s eating habits over the lunch time period as there was concern he was losing weight. The home has a comprehensive policy and procedure concerning the administration of medication. All staff receive mandatory induction training in administering medication but it is usually the most senior staff on duty that takes the responsibility for medication. The home’s medication record file was analysed and this contained all the up-to-date information about each resident’s health needs and their current medication is listed including information about what the medication is taken for and any contraindications. There was evidence of good liaison with the local pharmacy that provides medication to the home in a monitored dosage system. The pharmacist prints out a description of the medication so they can be easily identified. Records concerning the administration of medication were well maintained and accurate. The home must make sure that the dates packets are opened are recorded to facilitate auditing. This is particularly important when items have a shelf life such as eye ointment. There were clear procedures in place to cover any absences from the home e.g. staying with relatives. DS0000003961.V301891.R01.S.doc Version 5.2 Page 16 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 poor. This judgement has been made using available evidence including a visit to this service. Improvements are needed to the way complaints are recorded and staff would benefit from training in this area to ensure complaints are more effectively managed in the home. The home has satisfactory procedures in place to ensure service users are safeguarded from abuse; however, service users finances need to managed according to current regulations. EVIDENCE: The home has an appropriate complaints procedure in place and a leaflet about how to complain is available in a user-friendly format. The inspector examined the complaints log. The home needs to ensure the complaints log complies with the Data Protection Act and only one complaint is logged per page to ensure confidentiality is maintained. The inspector also felt that one complaint was inappropriately logged and was in fact an incident involving one service user displaying challenging behaviour and should have been recorded as an incident rather than a complaint. This was discussed with the team leader who acknowledged that the incident should not have been dealt with as a complaint. The inspector informed the team leader that this incident should have been reported to the commission in accordance with regulation 37 of the Care Homes Regulations 2001. It was also recommended that staff are given training in the complaints procedure and particularly what constitutes a complaint in order that complaints are dealt with more effectively in the home. DS0000003961.V301891.R01.S.doc Version 5.2 Page 17 Another member of staff also felt there was some confusion in the staff team about when to log complaints and felt that training would help to clarify these issues. The home has policies and procedures in place for the protection of vulnerable adults. These documents are detailed and informed staff of the correct procedures to follow. Staff also undertake training in the protection of vulnerable adults and evidence was seen on staff files to support this. During the inspection a sample of service users financial records was checked. Records and receipts were kept of all transactions and these were found to be correct. The inspector noted, however, that the service users personal allowance money appears to be going directly from their bank accounts to Prospects business accounts. This does not comply with the regulations as service users personal money should not be paid into the organisations account. Service users should be able to access their personal money direct from their bank accounts and this needs to be addressed. DS0000003961.V301891.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Marion House is well maintained and decorated to a high standard providing service users with a comfortable, attractive and homely environment. The standard of cleanliness is good providing service users with a hygienic environment. EVIDENCE: A tour of the premises was carried out as part of the inspection, including all the communal areas of the home and a sample of 4 service users’ bedrooms. The premises were well maintained and decorated in a homely way that was suitable for its stated purpose, i.e. providing care and support to adults with learning disabilities. Communal areas were found to be light, bright and comfortably furnished. The lounge and dining room had recently been redecorated. Service users bedrooms were observed to be personalised to each individuals taste with plenty of space for personal possessions. Two DS0000003961.V301891.R01.S.doc Version 5.2 Page 19 service users had recently taken the opportunity to move rooms after a vacancy had occurred in the home. These rooms had been re-decorated and furnished according to the resident’s choice. Service users confirmed they were very happy with their bedrooms and liked their living environment. Observation during the inspection also determined that service users had unrestricted access to all communal areas of the home. The premises were observed to be clean and hygienic with good procedures in place to prevent the spread of infection, e.g. separate hand washing areas and clear guidance in the preparation and storage of foods. There is a separate laundry room with impermeable walls and flooring. DS0000003961.V301891.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff on duty ensure the home is well run and organised, supporting the assessed needs of service users at all times. There has been a breach in staff recruitment procedures that needs to be addressed; as it is vital good standards of recruitment are maintained to safeguard the welfare of service users in the home. The home demonstrates a commitment to providing good quality training and all staff have the opportunity to complete a number of courses that reflect the homes aims and meet service users needs. EVIDENCE: Analysis of the rota and observation during the inspection demonstrated the home is well organised with satisfactory numbers of staff on duty to meet the assessed needs of service users. There is a mix of male and female staff and the rota is organised so that senior members of staff work with newer members of staff to ensure a good distribution of skill mix during shifts. The home does not use agency staff but has a regular team of relief staff who know DS0000003961.V301891.R01.S.doc Version 5.2 Page 21 the service users and understand the way the home works. There are currently 7 permanent care staff employed and 2 members of staff have achieved a NVQ Level 3. A further 2 members of staff are awaiting verification of achieving a NVQ Level 2 and 2 members of staff commenced NVQ Level 3 in May 2006. The home are therefore well on track to meet the target of having 50 of staff qualified to NVQ Level 2 or above. A sample of 3 staff records was examined as part of the inspection. Whilst all of the required documentation and information was in place for 2 members of staff, the inspector noted that a third member of staff’s work permit had expired. This was brought to the team leaders attention and an immediate requirement was issued for the home to resolve this issue. Staff contracts were observed specifying the terms and conditions of employment. All appointments are subject to a six-month probationary period. Volunteers and advocates were also subject to CRB checks. The home has an annual training plan identifying training needs for the whole staff team. Individual members of staff’s training is also logged. Records showed staff had attended a number of training courses including first aid, health and safety, food hygiene, fire training, prevention of abuse, medication, manual handling and infection control. It was noted that as well as the required courses ensuring safe working practices the home promotes additional courses that reflect the home’s aims and service users needs such as epilepsy, dementia and challenging behaviour. The team leader told the inspector that as well as an in house induction, all new members of staff also complete Learning Disability Award Framework accredited units in Induction and Foundation. Observation of practice showed that staff were accessible to service users and fully interacted with them during the inspection. Service users told the inspector they liked the staff, found them approachable and were able to discuss any problems or concerns with them. DS0000003961.V301891.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. The home needs to clarify management responsibilities and appropriately delegate tasks so staff are clear about their individual roles ensuring the effective management of the home. Feedback is sought about the quality of service from service users and their relatives but this needs to be included in a formal plan setting out aims and objectives for future service development. Outstanding health and safety checks and servicing have been carried out to ensure service users welfare is protected. DS0000003961.V301891.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager of the home has just returned after a period of long-term sickness. He is not yet working on a full time basis and has been having a period of induction back into the home and was therefore, not available on the day of the inspection. The team leader has been managing the home in the manager’s absence, although there had been no opportunity for a formal handover prior to the manager going off sick. This meant there had been some confusion over responsibilities in the home and this was evident in some of the requirements made during the inspection and the outstanding recommendations made at the previous inspection. The team leader said that she was waiting for verification that she had obtained NVQ 4 in care and she had commenced her Registered Manager Award in May 2006 with a view to eventually applying to become the registered manager of Marion House. It is recommended that now the manger is back at work responsibilities for all aspects of running the home be clarified to ensure the home is managed effectively. The home has a system in place for monitoring quality in the home. Questionnaires are sent from the Prospects Head Office to service users and relatives. These are then sent back to the Head Office where they are collated independently from the home. There was no evidence available at the inspection of the results of these surveys. There was also no copy available of an annual development plan for 2006, although the team leader said she had been working on this at home. An annual development plan needs to be made available with evidence that feedback has been obtained from service users and this has been incorporated into the plan. This would provide action points/targets to further improve the quality of service in the home. The responsible individual makes regular monthly monitoring visits to the home and a report of these is made available to CSCI. These are very comprehensive and provide a detailed analysis of all aspects of the home’s performance. The inspector examined records that showed that the home was meeting the requirements of other agencies such as Dorset Fire and Rescue Service and Environmental Health Department. Certificates were in place demonstrating that equipment and facilities were regularly serviced and maintained including those for electrical systems and gas safety that had been required at the previous inspection. The home had clear policies and procedures relating to health and safety practices. The manager confirmed her awareness of relevant legislation and certificates were in place showing staff had attended various training courses in safe working practices. The inspector recommended that a chart of staff fire training be kept in order to facilitate monitoring and ensure staff were meeting the current recommended levels of training. DS0000003961.V301891.R01.S.doc Version 5.2 Page 24 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 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 1 X X 2 X DS0000003961.V301891.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA22 Regulation 37 Requirement The registered person must notify the Commission of any event in the care home that adversely affects the well-being or safety of any service user. The registered person should not pay money belonging to any service user into a bank account unless the account is in the name of the service user(s) and is not used in connection with the carrying on or management of the care home. The registered person needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. The registered person must obtain all the information in respect of care workers in the home identified in Schedule 2 of the Care Homes Regulations 2001 and specifically ensure a valid work permit is in place. Timescale for action 01/08/06 2. YA23 20 31/08/06 3. YA32 18 31/10/06 4. YA34 19 14/07/06 DS0000003961.V301891.R01.S.doc Version 5.2 Page 26 5. YA39 24 The registered person must make an annual development plan available to CSCI with evidence that feedback has been obtained from service users and this has been incorporated into the plan. This would provide action points/targets to further improve the quality of service in the home. 30/09/06 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 YA9 Good Practice Recommendations It is recommended that the file be re-organised so that individual risk assessments relating to each service users are clearly filed for ease of reference. Any gaps in assessments will then be able to be identified and additional assessments completed as necessary It is recommended that service users are given more opportunities to prepare and cook their meals. The home must make sure that the dates medication packets are opened are recorded to facilitate auditing. This is particularly important when items have a shelf life such as eye ointment. The home needs to ensure the complaints log complies with the Data Protection Act and only one complaint is logged per page to maintain the complainants complete confidentiality. It was recommended that staff are given training in the complaints procedure and particularly what constitutes a complaint in order that complaints are dealt with more effectively in the home. It is recommended that management responsibilities and delegated tasks for all aspects of running the home be clarified to ensure the home is managed effectively. It is recommended that a chart of staff fire training be kept in order to facilitate monitoring and ensure staff are meeting the current recommended levels of training. 2. 3. YA17 YA20 4. YA22 5. YA22 6. 7. YA37 YA42 DS0000003961.V301891.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000003961.V301891.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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