Inspection on 08/06/06 for Martha House

This inspection was carried out on 8th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 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 14/03/06

Martha House 16/12/05

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 8 and 9 June 2006 10:30 Martha House DS0000027684.V302043.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 Martha House DS0000027684.V302043.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. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Martha House Address Hampton Green Old Eign Hill Hereford Herefordshire HR1 1UB 01432 279314 01432 271585 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.martha-trust-hereford.org.uk Martha Trust Hereford Limited Mr Peter Andrew Leach Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home may accommodate younger adults aged 18-65 years with a learning disability and who also have a physical disability. The home may accommodate children who also have a physical disability. 14th March 2006 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.V302043.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced visit taking place over one and half days. One inspector visited to observe the midmorning and day’s schedule for service users. The majority of service users were met. Discussions were held with staff and the registered manager. A random selection of records were examined. All twenty-two standards were assessed on this occasion. What the service does well: What has improved since the last inspection? What they could do better: • • • • • • • The Trust needs to ensure the appropriate levels of permission for taking photographs are acknowledged in the care plans. The role and involvement of advocacy services needs to be considered and in particular facilitating autonomy and choice with service users. The health planning record needs consolidating to provide clear evidence of meeting all health needs comprehensively. This will ensure all healthcare support provided is meeting needs. Care staff should receive training related to raising awareness of the management of medication at the home. This will develop their knowledge base. The areas relating to vulnerable adult and child protection for updating current guidance needs reviewing. This will ensure that procedures can be reviewed and service users protection will be met. All care workers should be receiving accredited training related to learning disability to underpin knowledge. The home needs to increase the levels of record supervision to achieve the expectation of the standards. This will enable effective management of supervising staff. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 6 • The Trust needs to develop a comprehensive quality assurance process that reflects a continual cycle of review and improvement. All stakeholders and the commission should be informed. 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.V302043.R01.S.doc Version 5.2 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.V302043.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The process for admissions are understood and staff are provided with the tools to carry out assessments. Families are contributing to this process. EVIDENCE: The Trust has a procedure in place for all new admissions to the home. An initial assessment is carried out and information gathered from relatives and carers contributes to this process. Most service users have a completed community care assessment and the core needs are clearly identified. The registered manager and senior nursing staff are responsible for the assessment of all new admissions. The assessment tool model is based on a nursing tool and modified due to the requirements of Martha Trust. The Trust offers long-term placements and a limited number of respite placements for children. Since the last inspection there have been no new admissions. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have an oversight of changing needs and the keyworker role is well developed. Caring planning is well implemented. There is scope for the Trust to develop links with outside advocacy services. EVIDENCE: All of the service users have a documented care plan. The care plans sampled were found to be comprehensive, coherent and well thought though. The staff are enabling the care plans to be accessible. The use of technology in particular digital photographs was evident. This strengthens the care plans as the reader can be guided through with the use of photographs. At a future stage the Trust should acknowledge that consent and permission has been sought for the use of photographs, records are being kept centrally and signpost this in the care plans. Risk assessments are incorporated in the care plans and are at a basic level. Overall the assessment of risk and potential for injuries is well considered. The area related to rehabilitation and physiotherapy is discussed. All of the service users are allocated a keyworker and co-worker. Keyworkers are responsible Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 10 for the review of the care plans and risk assessments. There was evidence of this being achieved on the plans sampled. The care plans identify when individuals are at risk by behaviours related to self-injury. One file examined demonstrated how care practices were modified with the use a wrist cup. Staff discussed that there is a conscientious effort to review and update care practices. There were good examples of consultation found in the files sample for children who stay for respite care. Staff were contacting parents prior to the child’s stay to update information. Any change with the child’s structure and routines is then added to the case files. The area that was considered weak relates to the lack of advocacy involvement. The Trust has clearly indicated that parents do not wish for separate advocates to be appointed. Nevertheless no information is available related to this service should a service user require such assistance. The registered manager should find out what has and not worked locally. Staff training should consider the role of advocacy including the key principals of best practices related to autonomy and choice. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 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): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to provide a variety of activities that match the needs of individuals. Both in house and community activities are well organised. Relatives are remaining in contact and take an active interest in the quality of care being provided. The staffing ratio reflects and matches the high level of needs of service users. The Trust recognises the value of employing qualified staff in relation to physiotherapy, music and therapeutic sensory and massage experts. EVIDENCE: The Trust employs a designated activities co-ordinator. Her responsibility is to organise on site and community based activities. This role is well developed and all care staff have a clear understanding of the expectations of supporting service users in a range of activities. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 12 During the visit service users were observed using the hydrotherapy pool, one to one physiotherapy, music therapy and accessing a community based college course. The college courses participated in, provided opportunities to develop friendships for service users. The homes environment is equipped to a high standard and specialist equipment including overhead hoists, standing physiotherapy frames, soft play equipment and trampoline is being regularly used. Staff were observed to be confident using this equipment. There are also two designated sensory rooms both fully equipped with an extensive range of equipment for tactile and sensory development. In addition, the Trust employs two physiotherapists and staff commented on the positive support and training received. Staff are expected to participate in the service user’s exercise routines. One service user spoken to, was observed to enjoy the sessional work. The therapeutic work-taking place included ‘Rebound’ therapy organised by the physiotherapist. Sessions are also organised to include building on experiencing life skills and this includes cooking with service users own designated kitchen and pet care involving visiting dogs to the home. There is a formal handover periods between the change of shifts and service users who need to attend appointments or any other commitments are organised. The nurse in charge of the shift ensures each service user is allocated a named member for support. The change over was observed to be well organised. Records are kept of any follow up actions between each shift change. Service users who practice their religion also attend the local church. Other service users attend coffee events and local fetes. The staff reflect the backgrounds of the service users and the mix of staff from different ethnic backgrounds is good. Families remain in contact and do visit at short notice. Some service users go home for weekend stays or over nights. And a couple of families visit twice a week. The home has ample space for visitors to be received in private without disturbing other service users and there is also a designated family room. The activities coordinator ensures that summer events including away days are circulated to relatives to assist with plans for any visits. The majority of service users use wheelchairs and are dependent on staff to move around the home. Staff discussed how service user’s responses and reactions were observed and gauged. This included hand gestures and eye movements. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 13 The home employs catering staff who are qualified. The meals are all prepared from fresh ingredients and seasonal vegetables and fruits are incorporated in the menu planning. The Trust has ensured input from the dietician. Records relating to weight monitoring are also in place. Meal times require high levels of support from staff. Service users can need up to 1 hour intensive support with eating their meals. During the visit there was enough staff available to facilitate this support. Service user’s likes and dislikes are clearly recorded in relation to menu planning and the food prepared and served. The dining room is spacious and during the summer meals are taken out doors. Martha House DS0000027684.V302043.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are confident and able to provide support at a personal level that pays good attention to maintaining dignity and respect. The environment is adapted to match the needs of service users with complicated disabled support needs. There are good systems in place for the safe control and administration of medication. The nursing staff have a clear understanding of their roles and responsibilities in relation to the administration of medications. The training for care staff should raise awareness of the management of medication in the home. The Trust should consider consolidating information related to health and providing a comprehensive health care tool that ensures all the necessary screens and health checks are taking place. EVIDENCE: The Trust provides a policy and procedure in relation to how personal care is organised and to be carried out. Staff awareness related to privacy and maintaining dignity is understood. The bathrooms are adapted to provide an appropriate environment for service users with complex physical disabilities. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 15 The care plans set out each person needs related to their morning and night time personal care needs. Personal hygiene and specific health routines are also recorded in the care plans. Service user’s preferred clothing and appearance is reflected at an individual level. The staff are provided with an extensive range of moving and handling equipment. Staff are expected to attend training organised by the physiotherapist related to maintaining safe practice for moving and handling. The Trust has available a policy related to Health Care. Health care professionals are being accessed including dentistry, opticians, and occupational health services. All appointments attended require staff support and input. Records are kept in the case notes and at the point of reviews health related matters are discussed. There is no one document that comprehensively addresses all elements of health and the Trust should consider how this information could be consolidated. This is particularly relevant to health care screening and the management of medical conditions. The home has reviewed its arrangements for medication. The Trust recognised the procedures needed strengthening. One senior member of the management team has been tasked with providing a clear system to audit the medications received, dispensed and disposed. The records sampled provided evidence of a clearer system in place. The staff member recognised some medications balance of stock need to be chased. The Trust also contacted the Pharmacist Inspector about the safe disposal of medications, as the local pharmacist no longer accepts returns. A contract has been set up with a approved licensed provider. All medications are stored in a designated medication room and proper medical storage cabinets are available. There is a clear system in place for controlled medications. All medications dispensed are prepared by the nursing staff and administrated. There were no gaps found in the records relating to medication. It is recommended that all care support staff should receive training related to raising awareness of the management of medication in the home. Care workers are involved in applying external medication for example creams or ointments when service users is being washed or bathed. So providing care workers with this training is important. There are some service users who are administered medications through Gastrostomy (PEG). The training has been extended to include the administration of medicines by this specialist technique. Martha House DS0000027684.V302043.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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to deal with complaints and the Trust is transparent about recording complaints. Some development work needs to take place to ensure that service users can access the complaints procedure effectively. The Trust needs to ensure that all publications relating to protection and safeguarding of children is obtained and available at the home for senior managers to refer to. The child protection policy and procedure should be amended in light of these changes. EVIDENCE: The Trust has available a complaints policy. It is recommended that at the point of the next review this document should clearly signpost all stakeholders to the Local Authorities own policy and information should be made readily available. There was some discrepancy between timescales described in the policy and in the Statement of Purpose. This was discussed with the manager during the feedback session. Since the last inspection the registered manager has introduced a log that relates to complaints. This meets with the expectations of how complaints records should be maintained. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 17 The only area identified as a gap relates to the complaints procedure. It is not readily accessible to service users and the registered manager must deal with this and locate the resources to address this situation. Discussions with the registered manager indicated that some key documents related to protection should be available in the office for ease of reference. The home also needs to amend its child protection policy in light of the new changes and the implementation of the safeguarding boards. The registered manager should also be trained at Level 2 accredited to Area Child Protection Committee (ACPC). There are clear structures in place to manage service users’ money and records are kept in the case files. Martha House DS0000027684.V302043.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): 24,30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well maintained and kept to a good standard of cleanliness. EVIDENCE: The home is a purpose built building that is furnished and resourced to a high standard. The Trust has over time invested in extensive equipment to provide an environment that is stimulating to service users with physical and sensory impairments. The accommodation is clean and well maintained. The Trust employs designated people including cleaners and a maintenance person. Good attention is also paid to the external grounds and maintenance. All of the bedrooms are decorated to individual taste and there was variety within this. Families, where appropriate, were involved in the decoration of the bedrooms. The Trust has available an infection control policy and this is a comprehensive document. The arrangements for laundry and sluicing are suitable. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Trust employs qualified nursing staff. Care support staff are well supervised. The training programme is well structured to match the varied needs of service users. Minor improvements are necessary with the frequency of supervision arrangements. EVIDENCE: The Trust operates good recruitment procedures. There is a mix of advertisements in the press and staff can approach the Trust directly. Four new staff member’s files were examined and all the necessary recruitment checks were in place including CRB checks, application forms and interview notes. References were available. It is advised that verbal contact is made to verify and validate the content of at least one of the references given and a record of that conversation is made. All new staff are expected to undertake a induction programme and are supernumerary to the staffing arrangements. There is a designated mentor for an agreed period of shifts. All staff are subject of a six month probationary period. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 20 Service users are not involved in the selection process. Candidates are invited to visit the home prior to or as part of the interview. Care assistant staff are not receiving copies of the General Social Care Council code but the Trust intends to rectify this. A large part of the training programme offered at the Trust is provided inhouse by trained staff. Topics covered at training events included sensory music therapy, oral tract therapy and Cerebral Palsy and Retts Syndrome. There was an extensive programme related to health conditions. Discussions with staff indicated that this was experienced as a supportive framework and consider it relevant in the practice setting. It is recommended that consideration be given to ensuring that all care staff are trained to Learning Disabilities Awards Framework (LDAF). Staff working in learning disabilities service should be provided with this underpinning knowledge. The New Skills for Care Induction under the Skills for Care should also be explored as this takes account of the updated version related to LDAF. There is a training programme in place to ensure the number of staff qualified at NVQ level 2 is achieved. Staff are receiving formal supervision four times a year. This includes a 3 month and 6 month review. It recommended that supervision be increased to meet with expectation of the standards. There is informal supervision, which has a non-structured format that gives team members opportunities to approach senior staff and the manager. Staff discussion indicated staff felt confident with approaching senior staff. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 21 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has met the qualification standards. The Trust has not developed an effective quality assurance system that analyses the strengths and weaknesses of the service. EVIDENCE: The registered manager is a qualified nurse with 20 years experience working at management level and has obtained NVQ level 4 in 2003. The registered manager has undertaken a periodic training related to IT, a disciplinary investigation course and a NVQ new standards course. Training organised inhouse has also been attended. The manager considers that his management style is very hands on a day-today basis. The Trust is clear about the organisational structure and focussed on the roles and responsibilities of the registered manager. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 22 The Trust recognises that the quality assurance for the service needs to be developed. There are elements related to medication monitoring and staff training in place. The quality assurance process should be built around the people who are using the service. Measurement is a vital part of continuous improvement and it permits a clear understanding of how things work. The Trust needs to develop a process of self-assessment and compare the quality criteria integrated into everyday activity. Once the quality assessment process is set up the cycle must be maintained and consequently improves over time, raising overall performance and meeting the needs of stakeholders. The monthly monitoring visits are carried out on time but remain at a basic level. Action points are not identified and consequently no follow up action takes place. There was evidence of health and safety matters being acted upon. Fire safety was addressed in the policy and records reflected ongoing training. The fire drills are meeting the expectations of the standards. The first aid boxes are well located around the home. Staff are receiving training as part of the induction process and senior staff are attending a two-day training course in First Aid. The arrangements for domestic installations were checked and were found to be within the timeframe for maintenance. Risk assessments are being carried out and the registered manager is responsible for reviewing these. All accident records are being kept centrally and it is recommended a copy be retained also in service user’s files. Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 23 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 2 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 1 x x 3 x Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes. Relating to the Regulation 26 visits. 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 YA39 Regulation 26 Requirement The registered manager must address the monthly visit reports. The quality of selfmonitoring must include information that is transparent about the visit; the type of records sampled and provide a comprehensive record of the visit. Time scale set. 28/02/06 & 30/05/06 not met. All care assistant staff must receive copies of the General Social Care Council booklets. All staff must receive formal supervision in accordance with the elements set out in standard 36.4. The registered manager and The Trust must develop a quality assurance system that captures all the elements outlined in standard 39. All accident records must be retained in service user’s files. Timescale for action 31/08/06 2 3 YA34 YA36 18(4) 18(2) 31/08/06 31/08/06 4 YA39 24 31/08/06 5 YA42 14 Schedule 3 31/08/06 Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA6 YA7 Good Practice Recommendations Permission sought for the use of photographs should be acknowledged when used in the care plans. The registered manager should develop links with advocacy services. Contact details for the British Institute of Learning Disabilities should be pursued. The registered manager should develop a comprehensive health care plan that ensures health care screening and medical conditions are fully addressed. Care staff should receive training related to raising awareness of the management of medication. The registered manager should also be trained at Level 2 accredited to Area Child Protection Committee (ACPC). The Trust should consider care staff being trained to the updated version of the Learning Disabilities Award Framework. YA19 YA20 YA23 YA32 Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Martha House DS0000027684.V302043.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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