Inspection on 22/11/07 for Marley Grove (6)

This inspection was carried out on 22nd November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marley Grove (6) 07/11/08

Marley Grove (6) 18/01/07

Marley Grove (6) 23/06/06

Marley Grove (6) 08/03/06

Marley Grove (6) 19/12/05

Marley Grove (6) 18/10/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Marley Grove (6) 6 Marley Grove Crownhill Milton Keynes Bucks MK8 0AT Lead Inspector Maureen Richards Unannounced Inspection 22 November 2007 09:45 nd DS0000015063.V339268.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 DS0000015063.V339268.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. DS0000015063.V339268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marley Grove (6) Address 6 Marley Grove Crownhill Milton Keynes Bucks MK8 0AT 01908 260005 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.macintyrecharity.org MacIntyre Care Mrs Amanda Anstey Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000015063.V339268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 3 persons with a learning disability. Date of last inspection 31st January 2007 Brief Description of the Service: Numbers 1 and 15, Baxter Close and 6, Marley Grove are three separately registered services located in Crownhill, Milton Keynes. They form a small service group providing accommodation and support to nine adult service users with learning disabilities. The homes are located within a short walking distance of each other in a small close in an area with reasonably good public transport to the city centre. There is a corner shop at the end of the road. The service is part of the MacIntyre Care organisation, an established provider of care for people with learning disabilities. At the time of the inspection the residents of Baxter Close included two married couples. The group of homes is managed from Marley Grove, which also provides accommodation for three service users requiring higher levels of support. The staff team works as one group, flexibly covering the needs of service users in all the three settings, rather than being specifically allocated to one or another. Together, Marley Grove and Baxter Close aim to enable people with learning disabilities to live as independent lives as possible. Fees range from £30,048 to £40,868 per annum. DS0000015063.V339268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over the course of a day with a follow up visit for 2 hours on a second day. The day included inspection of 6 Marley Grove and 1 and 15 Baxters Close which is managed from Marley Grove and have the same administration systems in place. The inspection covered all of the key National Minimum Standards for younger adults. Service users attend day services each day and as a result the home is unstaffed for periods of the day. Therefore the home was given 24 hours notice of the inspection to ensure that a member of staff was available for the inspection. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion and comment cards were sent to service users, relatives and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the acting senior and support staff, opportunities to meet with service users, examination of some of the home’s required records, observation of practice and a tour of the premises. On day 2 the inspection included discussion with the registered manager. Feedback on the inspection findings and areas needing improvement was given to the staff during and at the end of the inspection. The staff and service users are thanked for their co-operation and hospitality during this announced visit. What the service does well: The home has an admissions procedure in place although this has not been tested, as there has been no admissions to the home in the past twelve months. Service users are supported to have a varied and weekly programme of day centre activities including work placements Contact with family and friends is maintained to promote social links. Systems and procedures are in place to deal with complaints and to ensure the protection of service users from abuse. The home is clean and nicely decorated with service users bedrooms personalised and homely. DS0000015063.V339268.R01.S.doc Version 5.2 Page 6 New staff are inducted into the home and shadow experienced staff prior to working unsupervised on shift. Staff are appropriately supervised and feel supported in their role. Some documentation has been developed in a user friendly format and as appropriate for individuals. This continues to be developed on. Service users and relatives are happy with the care provided which promotes independence but with supervision and support from staff. Staff are approachable, knowledgeable and confident in their roles. What has improved since the last inspection? What they could do better: Up to date care plans must be in place for each service user. Care plans should be organised and accessible with information about individuals filed appropriately. Care plans must outline how individuals are supported to make choices and decisions. Service users meetings should take place as scheduled to give service users the opportunity to raise any issues and share their views. Service user plans must include up to date risk assessments to ensure the safety and well being of individuals. Opportunities and staffing must be made available to enable service users to take part in leisure activities and enjoy their hobbies. A record should be put in place to monitor how much leisure activities have taken place. Meals should be monitored to ensure that meals provided are healthy and nutritionally balanced. Staff at the home must act and monitor changes to individuals health. DS0000015063.V339268.R01.S.doc Version 5.2 Page 7 Medication practices must improve in relation to the use of homely remedies and as required medication to ensure the safety of service users. The pictorial complaints procedure should include telephone numbers and addresses to ensure service users know how to contact the relevant people. The Organisation should consider how relatives, professionals and funding authorities could be consulted as part of their annual quality audit of the service. Evidence of full recruitment checks for all staff must be maintained at the home to ensure the safety of service users. New staff and relief staff must have the required mandatory training before commencing work in an unsupervised capacity. The manager should ensure that the required health and safety checks are being carried out and that the records are kept up to date to support this. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000015063.V339268.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 DS0000015063.V339268.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. The home has an admissions procedure in place which ensures that the home is able to meet individual assessed needs, although this has not been tested as there has been no new admissions to the home in the past 12 months. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the information supplied on the Annual Quality Assurance Assessment document, there has not been any new admissions to the service in the past twelve months. Staff on duty confirmed this. However at the previous inspection it was assessed that this standard was met. The self Annual Quality Assurance assessment document outlines that MacIntyre has a comprehensive assessment document called Getting to Know You which is completed with the Service User and fully involves their family and other significant members in their circle of support. This ensures that individuals are suitably assessed and are provided with a service that suits them and meets their needs. The home indicates that they ensure that by following the Moving into MacIntyre procedures any transition into a Service is completed at a pace that best suits the individual an dthe others Service Users living within the Services. DS0000015063.V339268.R01.S.doc Version 5.2 Page 10 Transition consists of visits, planned meals, social activities, overnight stays and anything else that is required on an individual basis to ensure a smooth transition. DS0000015063.V339268.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,Quality in this outcome area is poor. Up to date care plans and risk assessments are not available which potentially put services users and staff at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service user plans were viewed, one from each of the services being inspected on the day. The care plan for the service user at this service was found to contain out of date support plans which showed no evidence of review and updating to reflect current needs and was not developed in the new format to outline support required in meeting personal and healthcare needs. This file also contained care plans for another service user at the home. The file was disorganised, overcrowded and as a result was falling apart with loose bits of paper/information falling out of it when being used. This is unacceptable administration of this file and must be addressed as a priority with an up to DS0000015063.V339268.R01.S.doc Version 5.2 Page 12 date care plan being developed and information pertaining to another service user being stored appropriately. The annual quality assurance assessment outlines that each service user has a linkworker and that the linkworker works closely with the individual to assist in identifying needs and choices through meetings, 1:1 sessions, annual reviews and day to day working. Care plans seen showed evidence of reviews but no records of one to one meetings. The annual quality assurance assessment outlines that staff also have resources within the Organisation to support individuals in making choices e.g. Care Practice Advisor. It was not clear how this resource was being utilised to develop staff in promoting service users choices and decisions. The manager confirmed that this post is new and has yet he has not been involved in working with individuals or staff in developing service users involvement in choices and decisions. The annual quality assurance assessment outlines that service Users take an active role in day to day choices such as menu planning, leisure activity choices, purchases and spending of their own money, decoration of their home and furnishings. Staff confirmed that the home has weekly service user meetings where service users are given the opportunity to make choices in relation to aspects of their lives. The meeting minutes indicate that the meetings have not been taken place weekly. The care plan seen do not outline how individuals are specifically supported to make choices and decisions. This needs to be further developed. Service users were observed being supported by staff to make choices and decisions in relation to their needs on return from day services. The care plan seen as outlined above contained a risk assessment which was dated 12/01/04 and showed no evidence of review. This must be addressed as a priority. DS0000015063.V339268.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17,Quality in this outcome area is adequate. Service users are supported to have a varied and weekly programme of activities, they are supported to maintain contact with family and friends and are provided with regular meals which suits their lifestyle, however opportunities for leisure activities need to be further developed to allow them the opportunity to pursue leisure interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users have a full weekly programme of day services activities which include work placements, education and training. The home has it’s own transport and staff are responsible for taking service users to and from activities. During the inspection arrangements were being made to support one service user with a leisure activity at the weekend. Staff confirmed that leisure activities have to be planned to enable staff to be available to support. The current staffing arrangements of one staff member per shift does not allow for DS0000015063.V339268.R01.S.doc Version 5.2 Page 14 any spontaneous activity or one to one activity. This will be referred to under the staffing section of the report. A record of individual activities are recorded in each service users daily record therefore it is difficult to get an overview of what leisure activities have taken place over the course of a week/month to assess fully if leisure interests are being supported. The home should set up a record to confirm what leisure activities have taken place. In comment cards received from service users one service user commented that “I cant go out because others want to stay in”. The annual quality assurance assessment outlines that service Users involve their families when they wish in their Annual Review meetings and plans.Comments received from relatives inidcate that they are kept informed of what is happening and are involved in their relatives care as approriate. Staff confirmed that there are no restrctions on visitors to the home. Service users at the home are supported to be independent and were observed being supported and encouraged to use their own key to enter their home and their bedroom. Relatives commented that independance was promoted and encouraged. Service users are supported to be involved in household tasks with all service users taking an active role in meals, setting the table and clearing up. Service users have three meals a day with drinks and snacks available in between. Service users are supported to choose their own breakfast and are involved in the prepartion of their packed lunches to take to the day service. The weekly menu is agreed at the house meeting and service users are asked daily if they want whats on the menu. Service users have the option of an alternative if required. The home records what was actually eaten which indicates that alternatives are provided.The records also indicates that on some weeks service users had chips on four occasions and pies on at least two occasions. This needs to be monitored to ensure that service users are provided with a nutritionally balanced meal.Service users indicated that they are happy with the meals provided. DS0000015063.V339268.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. Service users healthcare needs are monitored but changes are not acted on to promote service users well being. Some medication practices are unsafe and could potentially puts service user at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were heard supporting a service user with their personal care needs in private in a sensitive and caring manner. Times for getting up are planned to ensure service users are ready for their day service attendance. Times for getting up at the weekend are more flexible. The service user plan seen did not include the updated format of personal care plans and therefore did not outline specific guidance in relation to meeting care needs and in making choices in relation to clothes and appearance. Service users have a linkworker at the home. Staff confirmed that they are responsible for liaising with other disciplines in relation to that person including regular reviews with day services. Annual review records seen support this. DS0000015063.V339268.R01.S.doc Version 5.2 Page 16 Annual reviews reports are developed in a user friendly format and as a result are more accessible to service users. There was evidence of healthcare screening with records maintained of the outcome of health appointments with Dentists, Opticians, Podiatrists, General Practitioners, Speech and Language therapist and other specialist as required for individuals. A recommendation was made at the previous inspection that the Organisation should purchase a set of scales, which can be utilised as a resource for all of it services. Staff confirmed that this has been made available at the day services. In the service user file viewed it was noted that this individual was weighed in April and October 2007 and on each occasion had lost weight resulting in a total weight loss of seven pounds in six months. However there was no indication in the service users file that any action had been taken to address this and the care plan, which was out of date made no reference to monitoring this. This must be addressed. None of the service users at the home self medicate and named staff are responsible for administering medication, however this list needs to be updated to include the new staff member and acting senior. The medication is stored in a locked cabinet situated in the office. The home uses a monitored dosage system and printed medication records. Records of drug administration were found to be in good order with no gaps evident alongside prescribed dose times. It was noted the home had no controlled drugs at the time of this visit .The home has a record of disposal of medication back to the pharmacy. The medication records indicate that some service users take regular homely remedies for example cod liver oil, cold flu beechams. The medication policy outlines that homely remedies what has been agreed can be administered. However there is no evidence of what has been agreed and by whom. Therefore this must be addressed. The medication records indicate that some service users are given as required medication mainly pain relief. The medication policy outlines that to administer as required medication individual guidelines must be followed. However those guidelines were not included with the medication administration records and staff on duty were unable to locate them in service users files. Those guidelines must be put in place. New staff confirmed that they are assessed and deemed competent to administer medication. Medication assessments records for the new staff member confirmed this. Some staff have attended medication training and other staff have been identified to go on this training. DS0000015063.V339268.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. Systems are in place to ensure service users views are listened to and acted on and to safeguard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Annual Quality Assurance assessment document outlines that no complaints have been received in the last twelve months. The complaints log seen at the home confirms this. No complaints have been made directly to the Commission by service users or their representatives about this service. Service user meeting minutes indicate that service users are asked if they have any complaints and their response noted. A pictorial complaints information is displayed on the notice board at the home which outlines who to contact including external agencies and the Commission. However this pictorial complaints display does not include the contact telephone number or addresses for external agencies or the Commission. This should be addressed. Service users and families indicated they knew how to make a complaint and the majority of feedback indicates that the service responds appropriately to concerns raised. The Annual Quality Assurance assessment document outlines that there have been no safeguarding referrals. Staff on duty were clear of their responsibility in reporting safeguarding issues and a copy of the interagency procedure was DS0000015063.V339268.R01.S.doc Version 5.2 Page 18 available for reference if required. Training records indicate that all staff with the exception of the new staff have attended safeguarding of vulnerable adults training. DS0000015063.V339268.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good, The home is clean, nicely decorated, personalised and homely promoting a positive environment for the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 6 Marley Grove is located close to a group of local shops and within easy access of Milton Keynes and local amenities. It is a single storey building, which is accessible for service users with a physical disability. The home has a communal lounge /dining area, separate kitchen which is adapted to meet the needs of the service user group, a separate laundry room, bathroom with a parker bath and shower and a separate toilet. The home has adaptations such as grab rails and a hoist to support service users to maintain their independence. DS0000015063.V339268.R01.S.doc Version 5.2 Page 20 Each service user have their own bedroom which are personalised and reflects their interests and hobbies. The home has a small enclosed garden which the service users can access from their bedrooms. The home was nicely decorated, clean and homely. Staff are responsible for the cleaning at the home and cleaning schedules are in place to support this. DS0000015063.V339268.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34,35,36 Quality in this outcome area is poor. Staffing levels are not sufficient to meet service users needs, new staff and relief staff have not got the required mandatory training and some recruitment practices are unsafe which potentially put service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff confirmed that they are working towards a National Vocational Qualification and one of those staff members was being assessed during the inspection. A further two staff have confirmed they are to be enrolled on the course and one of the new staff members have obtained her national Vocational Qualification. Staff were observed to be accessible to and comfortable with service users. Staff confirmed that they had the skills and training to do the job expected of them. Some staff attended specialist training in autism and makaton in 2005/06 with training in dsyphagia and epilepsy in 2007. Specialist training should be included as part of the annual training programme to continue to develop staff skills and awareness. No comment cards have been received from other professionals but staff confirmed that they have developed good working relationships with other DS0000015063.V339268.R01.S.doc Version 5.2 Page 22 professionals. This was confirmed by the observation of telephone calls to other disciplines during the inspection. The home has recently appointed two support staff and a member of staff from another service has taken on the role of an acting senior. The rota seen indicate that there is two staff on duty each morning and afternoon shift with one staff providing care to the service users at Marley Grove and the other staff member providing support to the service users in 1 and 15 Baxter’s Close. The home is unstaffed at periods during the week when the service users are out at day services which allows for more flexibility with the rota. There is one staff member on duty at night who provides sleep in cover at Marley and would deal with any calls from Baxters. Staff are aware that they cannot leave Marley at night but would use the on call rota to get back up support if required for any of the Baxter services. Some progress have been made in addressing staffing levels and staffing levels have increased for the morning shift. The staff confirmed that the staffing levels are sufficient in the morning but that one staff member in each of the services in the evening make it difficult to meet service users needs at a time they would like. As identified under standard 13 staffing levels do not allow for individual one to one activities and service users at Marley Grove would have to go out as group, choose not to go or plan leisure activities in advance. This is unacceptable and must be addressed. The home do not use agency to cover vacancies and rely on their own staff and regular relief staff who know the service users to cover the shifts. It is hoped that the recruitment of two new support staff will address some of those. difficulties. A requirement was made at the previous inspection that the Organisation must cease providing support to service users at Stoney Stratford supported living service. Staff confirmed this had now ceased. Comments and feedback received from relatives and service users include that “they wish there was more staff” , “would be nice if there was less turnover of staff , on the other hand maybe the variety of personalities is good” Four staff files were viewed. The files seen included a checklist to indicate that two references and a Criminal Records Bureau check had been carried out prior to commencing work at the home. The files seen included various copies of identification for the individual. The home had no confirmation of recruitment checks for one of the relief staff working at the home. This member of staff work unsupervised in supporting service users and this must be addressed as a priority. During the inspection the National Vocational Assessor who is an ex member of staff from the home made arrangements to take a service user out to a leisure activity at the weekend. This is something she does regularly on a voluntary basis. The home had no documentation to confirm that this staff member had the required pre employment checks. This must be made available. DS0000015063.V339268.R01.S.doc Version 5.2 Page 23 The manager confirmed that service users are involved in the recruitment process however no evidence was available to support this. This should be developed on. Staff training records indicate that the staff have the required mandatory training, however new staff have not got the required mandatory even though one new staff member is working unsupervised in supporting service users either at Marley Grove or Baxters Close. Therefore it is essential she has food hygiene, first aid ,manual handling and fire safety training as a matter of priority to support her in this role and to ensure the safety of service users. The home has no confirmation of training for one of the relief staff working at the home in an unsupervised capacity and this must be made available to ensure that this individual have up to date mandatory training. New staff are inducted into their role and induction records for the new staff member confirm this. New staff shadow experienced staff in working with service users and this was confirmed by staff and was evident from the rota. All staff spoken with confirmed that they feel supported in their roles. Regular supervision is planned in advance and scheduled on the rota. Regular team meetings take place and minutes of team meetings seen confirm this. Staff confirmed that they are encouraged to contribute to the team meetings. DS0000015063.V339268.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. The home is generally well managed with systems in place to monitor the quality of care, however some health and safety practices must improve to ensure the health and safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager holds the National Vocational Qualifcation level 4 Registered Managers award. In the annual quality assurance documentation she has outlined that she has enrolled on the National Vocational Qualifcation level 4 in Health & Social Care award at a local college. Staff confirmed that they feel the home is well managed and that the manager is supportive and approachable. She has complied with requirements from the previous inspection in respect of this service. DS0000015063.V339268.R01.S.doc Version 5.2 Page 25 A number of requirements have resulted from this inspection and the manager must ensure that these are addressed within the agreed timescale. Monthly monitoring of the home takes place and Regulation 26 reports were available at the home to confirm this. Staff on duty were clear of who the service manager was should they need to contact her. The Annual Quality Assurance documentation outlines that the Head of Service and Area Manager complete monthly financial and budget checks to ensure that all monies are accounted for correctly and finances are not being abused. The organisation carries out a “Big Respect” audit. The report indicates that this audit is carried out over two days with time spent with service users observiing and recording staff practices.This audit does not include feedback or input from relatives, other professionals or stakeholders and the organisation should consider how this could be developed. New staff have not got the required mandatory training but one staff member is working unsupervised either at Marley’s/ Baxter’s. There is no confirmation of mandatory training for relief staff. A range of health and safety checks was in place at the service, carried out on a daily, weekly or monthly basis. A sample of those records, were viewed at this inspection. The health and safety check records for September and October were not filed in the health and safety folder. Portable electrical appliances had been checked in September 2007, the gas safety check was carried out in November 2006 and was now due. A fire risk assessment was in place for each service, which was due for review in September 2007. The home had weekly fire and monthly check records in place. The records indicate that the monthly checks for September and October had not been completed. A fire drill had taken place in June 2007. The home had a series of risk assessment which were reviewed in September / October 2007 . The records indicate that water temperature checks are carried out monthly and action taken to address issues identified. Daily fridge and freezer temperatures are in place. Records seen indicate that the parker bath and hoist have an up to date service. DS0000015063.V339268.R01.S.doc Version 5.2 Page 26 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 3 23 3 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 3 33 2 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 1 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 3 x x 2 x DS0000015063.V339268.R01.S.doc Version 5.2 Page 27 No 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 15 Requirement The manager must ensure that all service users have an up to date care plan in place, which meets their identified and changing needs. The manager must evidence how service users are supported to make individual choices and decisions. The manager must ensure that all service users plans include up to date risk assessments in relation to the management of identified individual risks. Opportunities and sufficient staff must be made available to enable service users to pursue leisure interests and activities. The manager must ensure that where weight loss of a service users is noted that appropriate action is taken to monitor or refer . The manager must ensure that confirmation have been obtained from the prescribing General Practitioner that homely remedies administered by staff do not interact with individuals prescribed medication. DS0000015063.V339268.R01.S.doc Timescale for action 31/01/08 2. YA7 12 31/01/08 3. YA9 13 31/01/08 4 YA14 YA33 16 29/02/08 5 YA19 12 31/12/07 6 YA20 13 31/01/08 Version 5.2 Page 28 7 YA20 13 8 YA34 19 9 YA35 13 &18 Guidance must be put in place on the administration of “as required” medication for individuals. Evidence of recruitment checks for relief staff and ex staff working in a voluntary basis must be maintained at the home. New staff and relief staff must have the required mandatory training before working on shift in an unsupervised capacity. 31/01/08 31/12/07 31/12/07 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 6 7 Refer to Standard YA6 YA7 YA17 YA14 YA22 YA39 YA42 Good Practice Recommendations Service users files should be reorganised and made more accessible to ensure that service users personal information do not get mixed up. Service users meetings should take place weekly as scheduled and if a meeting does not take place a record should be maintained as to why. Meals must be monitored to ensure that a nutritionally balanced meal is provided. A record should be maintained of what leisure activities have taken place. The pictorial complaints display should include telephone numbers and addresses. The organisation should consider how relatives, professionals and stakeholders can be consulted as part of an annual quality audit. The manager should ensure that all health and safety checks are carried out and that systems are in place to monitor this. DS0000015063.V339268.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000015063.V339268.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!