Inspection on 16/12/05 for Martha House

This inspection was carried out on 16th December 2005.

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

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

Other inspections for this house

Martha House 07/06/07

Martha House 08/06/06

Martha House 14/03/06

Martha House 13/03/05

Martha House 06/10/04

Martha House 26/02/04

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 Martha House Hampton Green Old Eign Hill Hereford Herefordshire HR1 1UB Lead Inspector Martha Nethaway Unannounced Inspection 16th December 2005 10:30 Martha House DS0000027684.V272107.R01.S.doc Version 5.0 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 Martha House DS0000027684.V272107.R01.S.doc Version 5.0 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. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Martha House Address Hampton Green Old Eign Hill Hereford Herefordshire HR1 1UB 01432 279314 01432 271585 enquiries@martha-trust-hereford.org.uk www.martha-trust-hereford.org.uk Martha Trust Hereford Limited 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) Mr Peter Andrew Leach Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate children who also have a physical disability. This home may accommodate younger adults aged 18-65 years with a learning disability and who also have a physical disability. 13th March 2005 Date of last inspection Brief Description of the Service: Martha House provides lifelong care for 12 people across a wide age range, which includes young adults and children. In addition, a number of people and their families are supported through the provision of 2 respite care beds. The mix of age groups is unusual and runs counter to mainstream philosophy and practice for social services. However, the service was specifically established to care for people who have profound intellectual and physical disabilities in response to a lack of such provision in the region; furthermore, the continuity of service beyond childhood is central to the philosophy of the service. The premises were purpose built and the facilities have been developed to address the needs of both individual residents and the group as a whole. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first unannounced visit taking place over five hours. One inspector visited to observe the midmorning and day’s schedule for service users. All of service users were met and one staff member provided a guided tour of the premises. Discussions were held with staff and the registered manager. A random selection of records was examined. What the service does well: What has improved since the last inspection? What they could do better: • Records relating to children in particular the ‘Looking after Children ’ LAC documents should be available on file for staff to refer to. This will ensure that the plan of care being provided and delivered is not isolated. Care files should be reviewed to ensure all records are being kept in respect of each service user. Accessing local advocacy services should be considered and the development of advocacy representation should be pursued. This will enable good practice models of consultation to be adopted by the Trust. DS0000027684.V272107.R01.S.doc Version 5.0 Page 6 • • Martha House • Consideration should be given to the development of a comprehensive health care plan. This will assist with providing a systematic approach to health care planning and any gaps will be easily identifiable. The complaints record should be improved to ensure all records are comprehensive and transparent. The quality of self-monitoring needs development. The area of monitoring and auditing is underdeveloped. • • 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. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Good systems are in place to assess service user’s needs. EVIDENCE: Martha Trust had available a policy and procedure for new admissions to the home. Martha Trust can accommodate adult service users and children for respite care. All prospective service users receive an application pack, containing information about Martha Trust. Parents, carers and social workers were consulted and contributed to the initial referral assessment process. Introductory visits are arranged to consider the suitability of the placement. The assessment format and the overall gathering of information were found to be helpful. There have been no new admissions to the home since the last inspection. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Care planning is well organised. The staff team use imaginative and creative ways of working with individuals and regularly consult with external professionals. The home is able to offer therapeutic input with service users. Good attention is given to the assessment of risks. Further improvement should be made in relation to obtaining all the necessary information for children. Care files should be reviewed to ensure all records are being kept in respect of each service user. Accessing local advocacy services should be considered. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 10 EVIDENCE: A recognised nursing assessment tool underpins the assessment of service users needs. Care records contained information relating to health, diagnosis and identified key areas for day-to-day support and care routines. Martha Trust is continually adapting and improving the quality of care plans. There were some excellent examples of care plans that used digital photographs to provide comprehensive guidance for staff. Children are also accommodated for respite care. It is recommended that all ‘Looking After Children’ (LAC) documents should be included in the child’s case notes. This will ensure that the plan of care is not delivered separately from other care arrangements for children. A review of the service user’s files should be conducted to ensure full compliance with all the matters identified in Schedule 3 of the National Minimum Standards Care Homes Regulations. The registered manager needs to ensure that any action that needs following up after reviews should be clearly illustrated in the care plans. The care plans need to demonstrate who has been consulted. Any restrictions or limitations in relation to care plans should be discussed and documented. A number of the service users have complex physical and learning disabilities. There were several good examples of external specialists being consulted to develop plans of care. Staff implemented plans for individuals in relation to physiotherapy, hydrotherapy and speech therapy. Service users had an allocated keyworker. Keyworkers liaised with parents and carers and are responsible for preparing monthly reports. Systems were in place for consultation with service users but could be improved by establishing links with local advocacy services. Risk assessments were available and incorporated in the service care plans. There was evidence to indicate that assessments were being reviewed. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, & 16 The staff team are able to provide an environment that carefully matches service user’s needs. Staff are providing input that is therapeutic and well resourced by professionals. Good attention is given to the development and maintenance of a varied and active lifestyle. Good resources are available in the home and community activities are regularly accessed. EVIDENCE: There is ample evidence of structured activities being organised by Martha Trust. This is a particular strength of the home and is well resourced. The home employs a designated activities co-ordinator. This enables the home to provide a broad and range of activities to service users. In-house activities are clearly organised. Service users and children have access to sensory rooms, both white and dark rooms. These were nicely equipped with a range of sensory stimuli including projected lighting, waterbeds, massage mattress, bubble tubes, aromatherapy and key touch Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 12 pads. Soft play areas and a ball pool are also available. There is a hydrotherapy pool that is regularly used. In addition there is a designated room for physiotherapy and standing frames. This room aids and assist the individual’s mobility and helps to maintain good exercise regimes. Rebound therapy is available and provided by a qualified therapist. Suitable and appropriate equipment is available including mobile hoists and overhead tracking hoists. Each service user had available a timetable of their daily schedule. The achievement of occupied time and free time appeared well balanced. The staff team show commitment to working with individuals that respects and promotes choice with daily living. Service users had access to an independent domestic kitchen that is designed for their exclusive use. Staff are able to provide one to one support with cooking. Regular access to community facilities was featured in the care records examined. This included trips cinema and theatre and shopping. The only areas identified as shortfalls relate to the individual care plans. There needs to be evidence of how incoming mail and correspondence is dealt with. Care plans should identify the service user’s preferred form of address, for example if they use a shorten version of their name. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Suitable arrangements exist to ensure personalised support is tailored to the needs of the individual. Health care needs are being addressed. Consideration should be given to the development of a comprehensive health care plan. EVIDENCE: Care plans clearly address how individuals receive personalised support. The staff team are committed to providing safe and caring working practices. Staff are offered training on the safe moving and transferring of individuals. Health care needs are examined and addressed in care plans but there is no one, over arching health care plan. Discussions with the registered manager indicated he was confident that health care is being monitored and reviewed by the staff team. One file examined showed the weight monitoring chart was not following the home’s own policy and practice. This was discussed with the registered manager during the inspection feedback. There were good examples of service users accessing primary health care professionals. Input was also being organised from psychiatric service and the learning disabilities community health team. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 14 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 & 23 Arrangements are in place to protect and safeguard vulnerable adults and children. A complaints procedure is in place but improvements should be made to ensure all records are comprehensive and transparent. EVIDENCE: Martha Trust emphasises it’s total commitment to parental and carer’s involvement. Consultation takes places by using a number of mechanisms including newsletters, fundraising events and open evenings. There is a complaints policy and procedure and Martha Trust takes all matters relating to complaints seriously. Documentary evidence was available but the paperwork was stored loosely. This was not in line with the expectation of the national minimum standards. It is recommended that a bound book be used that clearly shows the process of investigation, action taken and outcomes reached. This will better represent the efforts being made by the home in dealing with any concerns or complaints raised. There was one complaint logged since the last inspection and it had been appropriately investigated. It is advised that the registered manager should implement a proper recording system at the home to clearly record all allegations and incidents of abuse in line with Standard 23. There was one live issue relating to staff conduct that is currently being investigated. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 15 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 & 30 The home is well maintained and is comfortable. A good standard of cleanliness is being achieved. EVIDENCE: The home was found to be clean, comfortable and attractive. The home was well maintained. Every service user had their own room, which was equipped with a rise and fall bed, wardrobe and chests of drawers. The rooms had been personalised and were colourfully decorated. Some parent/s and carer/s had contributed to the decoration of the bedrooms. The home has an infection control policy and this enables staff to maintain safe working practices. Appropriate risk assessments were available relating to the environment. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 16 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): 34, 35 Good sound recruitment checks are in place. Staff are being provided with a varied programme of training. EVIDENCE: The recruitment practices of the home were checked. The files looked at were found to be well structured and organised. The files evidenced the completion of proper recruitment checks. Previous employers written references were available and checks by telephone had been carried out. All employees had available a CRB check. It is recommended that these be renewed every three years. All employees are subjected a probation period. Staff training was examined. There is a centralised mechanism to ensure core and mandatory training is being achieved. Records showed a varied selection of training courses. A system needs to be developed to ensure all staff receive continual professional development of at least five paid training and development days (pro rota) per year. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 The quality of self-monitoring needs development. EVIDENCE: The ethos of Martha Trust is to provide a quality service to individuals with complex physical and learning disabilities. Staff are capable and able to provide an area of expertise related to health care. There is a strong commitment from the staff team to work towards the achievement of this goal. The responsible individual conducts the monthly internal audit but these documents are limited in scope. The reports do not represent the unique service that is provided and neglect to signify to the staff their efforts in providing quality care. The monthly audits need to be more transparent about the records examined and provide comprehensive feedback to staff on areas for improvement and development. This will enable effective quality monitoring to be developed. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 4 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Martha House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x DS0000027684.V272107.R01.S.doc Version 5.0 Page 19 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 YA23 Regulation 13,16 Requirement The registered manager must ensure a record is maintained of all allegations and incidents of abuse and action taken in accordance with Standard 23.3. The monthly visit reports must be improved. The quality of self-monitoring must include information that is transparent about the visit; the type of records sampled and provide a comprehensive record of the visit. Timescale for action 28/02/06 2 YA39 26 28/02/06 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 Martha House Refer to Standar d YA6 Good Practice Recommendations The registered manager should ensure that care plan DS0000027684.V272107.R01.S.doc Version 5.0 Page 20 2 3 4 5 6 7 8 9 10 YA6 YA6 YA6 YA7 YA19 YA19 YA22 YA34 YA35 records correspond with any action to be followed up following reviews. Care plans should demonstrate who has been consulted and who has contributed to the plan of care. Any restrictions or limitations in relation to care plans should be discussed and documented. Care plans should identify how incoming mail and correspondence is being dealt with. The preferred name of a person should be recorded. The registered manager should organise involvement of a local advocacy service to consult further with service users. The registered manager should ensure that the records relating to weight monitoring are kept up to date. Consideration should be given to the development of a health care plan to comprehensively monitor and review health. A complaints log should be introduced and provide details related to the complaint, investigation conducted and action and outcome. CRB’s should be renewed every three years as a measure of good practice. A system should be developed to ensure all staff receive continual professional development of at least five paid training and development days (pro rota) per year. Martha House DS0000027684.V272107.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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