Inspection on 05/08/08 for Marula House

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marula House 15/11/07

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Marula House 54 Durham Road Manor Park London E12 5AX Lead Inspector Rob Cole Key Unannounced Inspection 5th August 2008 10:00 Marula House DS0000069527.V368917.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 Marula House DS0000069527.V368917.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. Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marula House Address 54 Durham Road Manor Park London E12 5AX 020 8514 3739 020 8514 3739 marulahouse@aol.com 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) Marula House Ltd Virginia Magagula Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Male whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3. 15th November 2007 Date of last inspection Brief Description of the Service: 54 Durham Road was registered as a care home in 2007. The registered person had previously provided a care service for younger adults with mental health problems at a previous location. The service was relocated to 54 Durham Road and registered with the Commission and as a new service. The property is a terraced family type home situation in a residential road, with easy parking. The property provided three single bedrooms one with en-suite shower room. Adequate shared toilets and bathing facilities were provided. A comfortable lounge was located on the ground floor and a domestic type kitchen, which included laundry facilities. The property had front and rear gardens. The rear garden was well maintained, had shrubs and plants and seating provided. The current fees ranged from £750 - £1150 per week Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This inspection took place on the 5/08/08 and was unannounced. The inspector had the opportunity of speaking with service users at the home, care staff, and the homes manager was present throughout the course of the inspection. The inspector was able to observe staff interaction with service users, and the inspection also included a tour of the premises, along with an examination of records and other documents. Prior to this inspection, the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. The CSCI sent questionnaires to the three service users currently living at the home, and all of these were completed and returned prior to the inspection. All of this has been included in the overall inspection process, and helped to form judgments made within this report. What the service does well: What has improved since the last inspection? What they could do better: Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 6 Despite these improvements, there are still some issues that must be addressed, and a total of seven requirements have been made as a result of this inspection. The home must ensure that any staff who administer medications are appropriately trained and assessed as competent, and that clear records are maintained of all medical appointments. Risk assessments must be person centred and based around individual service users, and the home must ensure that service users are given the opportunity of participating in a wider range of community based social and leisure activities. 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. Marula House DS0000069527.V368917.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 Marula House DS0000069527.V368917.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that prospective service users are provided with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service Users Guide in place, both documents are written in plain English, and have been subject to review within the past twelve months. The Statement says “We aim to provide a stable, safe living environment within a shared house; a comfortable, pleasant and culturally sensitive environment, and choice in all areas of residents lives.” The Statement also includes details of the management and the organisation, along with details of the services and facilities provided by the home. All residents are provided with their own copy of the Service Users Guide. This includes the homes complaints procedure and contact details of relevant Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 9 organisations such as community and advocacy groups, and is in line with National Minimum Standards (NMS). The home has an admissions procedure in place, which covers both planned and emergency admissions. The procedure makes clear that prospective service users would be able to visit the home before making a decision as to move in or not. Since the previous inspection there has been one new admission to the home, and the manager informed the inspector that they did visit the home once before moving in, and that they were offered the opportunity of further visits, but declined this offer. The resident was able to inform the inspector that they had indeed chosen to move into the home after the one visit. A senior member of staff from the home carries out a pre admission assessment on prospective residents before they move into the home to see if the home would be able to meet their needs and whether or not it would be a suitable placement. For the most recent person to move in to the home, the admission assessment was carried out jointly by the homes manager and proprietor. This assessment covered the residents background, their psychiatric history and medical needs. An assessment was also undertaken by the placing authority. All residents are provided with a tenancy agreement, which is signed by both the resident and the homes proprietor. These give details of fees payable and the rights and obligations of both parties. Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users have a large degree of control over their daily lives, and that they are given the opportunity of been involved in the running of the home. EVIDENCE: Care plans are in place for all residents. These have been drawn up with the involvement of the resident, their keyworker and the homes manager. Plans are clear and comprehensive. They clearly set out the needs of service users, and how the home is able to support them meet those needs. They cover needs around mental and physical health, along with equality and diversity issues, for instance around culture and religion. Care plans are subject to regular review. To help with the review process, service users have a weekly one to one meeting with their keywork, to discuss any issues of relevance to them, including goals set out in their care plans. Daily records are also Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 11 maintained. Each service user has an annual review meeting in conjunction with their placing authority, which feeds in to the care planning process. The home has drawn up a series of risk assessments around risks faced by service users. Some of these are person centred and individualised to a particular service user, for example there are assessments in place around been healthy, covering diet, exercise, regular health checks etc, or around self harm and self neglect. These are of a satisfactory standard, clearly identifying any risk and including strategies to manage and reduce those risks. They also include guidelines on managing any challenging behaviours that service users may present. There was evidence through the risk assessments and the AQAA supplied by the home that service users are able to take reasonable risks, for example accessing the community without the support of staff, which helps to promote and develop independence and dignity. However, some service user risk assessments are generic, in that a single assessment is in place covering all three service users, for example around cooking. Although different service users face different degrees of risk around cooking, and require varying levels of support, the assessment in place does not differentiate between the three service users. In order to promote the health, safety and welfare of service users and others, it is required that individual risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. Through observation and discussion there was evidence that service users have a large degree of control over their daily lives. It was observed that service users got up at varying times during the course of the inspection, all of which were at a time of their choosing. Service users informed the inspector that they are able to make decisions about their daily lives, such as when to get up and go to bed, when to go out, what to eat etc. One service user informed the inspector “I like been more free, it’s better then the hospital.” Service users were seen to be able to plan their own day, for example the care plan for one service user stated that on Tuesdays they attended a music group. However, on the day of inspection this resident informed staff he did not wish to go to the music group that day, but wanted to go to a local market instead, and this was seen to be facilitated. Service users have been offered keys to their bedrooms and to the front door. There was evidence that service users have the opportunity of been involved in the day to day running of the home. Service users are involved in daily routines, as detailed in their care plans, for example with cooking, laundry and keeping their bedrooms tidy. Regular service user meetings are held, these discussed issues such as menus and activities. It was seen at a recent meeting service users said they would like a BBQ, and this was subsequently arranged. Service users are involved in choosing and planning their own holidays. As the home was only registered within the past twelve months, as yet it has not needed any redecorating or new furniture. However, the manager informed the Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 12 inspector that as and when these things become required, service users will be given the opportunity of been involved in choosing any new décor, furniture etc. The home has a confidentiality policy in place, this makes clear under what circumstances a confidence may need to be broken in the health, safety and welfare interests of service users and others. Staff spoken to demonstrated a good understanding of the issues around confidentiality. Confidential records are stored securely, staff and service users can access their records as appropriate. Marula House DS0000069527.V368917.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): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live generally fulfilling and active lives. Food was of a good standard, and service users are able to access the community as they wish. EVIDENCE: Although no service users are currently involved in any employment, one service user has expressed a desire to work with older people, and the home is looking in to this. No service users are currently involved in any formal educational opportunities. Activities charts are in place for all residents as part of their care plans. One service user is a member of a music group run by Day Opportunities Service. All service users are able to access the community without the support staff, for example to the cinema, parks, and cafes. Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 14 The homes manager informed the inspector that it was planned that the home would also arrange some community based social and leisure activities, and there was evidence that service users would want this. For instance, the minutes of a recent service user meeting stated that service users would like the home to arrange a day trip to Madame Tussauds, but this has not been arranged, likewise, a service user informed the inspector on the day of inspection that they would like support to go swimming, but again, this has not been arranged. It is required that the home supports service users to access community based social and leisure activities in line with their assessed needs and stated preferences. In house service users have access to a variety of leisure activities, such as television, videos, music, board games and BBQ’s. Residents have access to community facilities, such as shops, markets, banks, post offices and libraries. Service users are able to access public transport, such as buses and trains. Care plans indicate that service users are encouraged to participate in religious festivals as appropriate, and their was evidence that service users have been able to personalise their bedrooms with religious iconography, thus helping to meet their needs around equality and diversity issues. One service user is a member of “Stars in the Sky”. This organisation seeks to help adults with learning disabilities meet people, and develop friendships and relationships, again helping to meet needs around equality and diversity issues. Residents are able to maintain contact with family and friends, including visiting families for overnight and weekend stays. Service users can see visitors in private if they so wish, both in their bedrooms, or the homes quiet room. Service users are given their own mail to open, and have access to the use of a telephone in private. Indeed, two service users have their own mobile phones. Service users have a large measure of control over food. They are able to choose and buy their own food, and cook it themselves, with staff support provided where needed. It was evident that service users are able to eat at a time of their choosing, and that meals were personalised to individual service users. Records are maintained of menus, and of fridge and freezer temperatures. The kitchen was clean and tidy, and food was stored appropriately. The home buys various basic food items such as bread, milk, tea, coffee and sugar for communal use by service users. Marula House DS0000069527.V368917.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 and 21. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is able to meet the personal care needs of service users. However, greater attention needs to be paid to meeting health care needs, for example around recording of medical appointments, and ensuring all staff are appropriately skilled and knowledgeable to administer medications. EVIDENCE: Care plans make clear that service users are able to manage their own personal care. It was noted during the course of the inspection that staff offered gentle encouragement to service users to attend to their personal care. All service users are registered with a GP, and the home has taken steps to register service users with other health professionals such as dentists and opticians. Records are maintained of medical appointments, these indicated Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 16 that service users have access to health care professionals as appropriate, including psychiatrists and CPN’s. However, these records are not sufficiently detailed. For example, the records for one service user stated they had a review meeting on the 14/5/08, but there was no information on whom this was with, or of any outcomes. Several other entries on the records of medical appointments state who the appointment is with, but then only say attended, there is no information on the reason for the appointment, or of any follow up action necessary. In order to appropriately monitor health checks, and help ensure that service users have access to health care professionals as appropriate, it is required that clear and detailed records are maintained of medical appointments, including details of any follow up action required. The home has a medication policy in place, and the inspector was pleased to note that this has been revised since the last inspection, and is now in line with NMS. The policy states that all staff must undertake training before they are able to administer medication, and that the home must satisfy itself of the competence of that member of staff to administer medications. The policy goes on to state that a record of this must be in place on the staff members file. The inspector spoke with a member of the care staff who has responsibility for administering medications, who informed the inspector that they had received a half days medication training. However, no record of any assessment of their competence to administer medication could be found in the home. In order to help ensure that medications are administered appropriately, it is required that all staff undertake appropriate training, including an assessment of their competence, and a record of this must be maintained. Medications are stored in a locked cabinet inside the office. No service users currently self medicate, or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. The home maintains Medication Administration Record charts. Those examined by the inspector were accurate and up to date. The manager informed the inspector that residents would be able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. However, the home has not sought the views of service users on their wishes for the arrangements to be made in the event of their death, and this must be addressed. Marula House DS0000069527.V368917.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 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home has taken reasonable steps to protect service users. Service users have a good understanding of whom they can complain to, and all staff have undertaken adult protection training. EVIDENCE: The home has a complaints log, this indicated that complaints have been investigated and recorded appropriately. The complaints procedure includes contact details of the CSCI. A copy is included within the Service User Guide, which all service users are provided with. There was also a copy of the procedure on display within the home. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home has a copy of the Local Authorities adult protection procedure, and also its own policy and procedure on adult protection. However, this is not in line with current legislation. The policy states that allegations of abuse made by a service user should only be referred to the Local Authority safeguarding team when the service user gives their consent, but in fact the home has a legal responsibility to refer all allegations of abuse, whether consent has been given or not. The policy also makes no reference to informing the CSCI of any allegations of abuse. In order to help ensure that the home handles any Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 18 allegations of abuse appropriately, the homes adult protection policy must be in line with current legislation. Staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. Records indicated that all staff working at the home have undertaken training in adult protection issues. All service users have their own bank accounts, and all go to the bank to withdraw their money. The home holds money on behalf of service users in a locked cabinet, with the agreement of the service users. Records are maintained of monies held by the home on behalf of service users, and service users are requested to sign whenever they take any of their money. Marula House DS0000069527.V368917.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): 24,25,26,27,28 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users are provided with adequate private and communal space. EVIDENCE: The home is located in the Manor Park area of the London Borough of Newham, close to shops, transport links and other local amenities. The home is in a quiet residential street, and is in keeping with other homes in the area. The communal areas of the home consist of a lounge, a dining room/kitchen, a second lounge used as a quiet room and a garden. The garden was well maintained, and included appropriate garden furniture. The home was Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 20 generally well maintained, both internally and externally. Furniture and fittings were well maintained and domestic in character. The home is registered for three service users, all of whom are provided with their own bedroom, one of which is ensuite. Bedrooms have been personalised to individual service users tastes, for example with family photographs and posters of football teams. Service users have been able to bring their own personal possessions in to the home with them, such as televisions and music systems. Bedrooms meet NMS on size requirements. Curtains, carpets and bedding in bedrooms was well maintained, and domestic in character. Rooms had adequate natural light and ventilation, and all bedrooms are centrally heated. Bedrooms contained appropriate furniture, including chest of draws, wardrobe, table and chairs. In addition to the ensuite bedroom, the home has one toilet/shower room and one toilet/bathroom. Bathrooms were clean, tidy and free from offensive odour. Since the previous inspection the inspector was pleased to note that all bathrooms are now fitted with a working lock, which includes an emergency override device. There was evidence that the home has taken steps to help control the spread of infection. Staff have undertaken training in infection control, and protective clothing such as gloves were available to staff. Hand washing facilities were situated around the home. The home has laundry facilities which are appropriate in scale to the size of the home, and COSHH products were stored securely on the day of inspection. It was however noted that one service user wrote in their survey that the home is fresh and clean “Sometimes.” The current group of service users do not require any specialist adaptations or equipment to aid them with their mobility around the home. Marula House DS0000069527.V368917.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): 31,32,33,34 and 35. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: Home provides 24-hour support, including a waking night staff and an emergency on-call procedure. The home had a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. For most of the time the home operates with one staff member on duty, but two days a week there are two staff on duty, one of whom is the manager, which provides them with an opportunity to work on administration and management duties. Through observation and discussion there was evidence that staff have built up good relations with service users. Staff were seen to be chatting in a relaxed and friendly manner with service users throughout the course of the inspection. Service users expressed satisfaction with the staff, one commented Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 22 “I like them.” Staff are provided with a copy of their job description, and the home holds regular staff meetings. All staff undertake a structured induction programme on commencing working at the home. This includes a period of working supernumery, shadowing more experienced members of the staff team. Staff have access to regular training. Recent training has included adult protection, food hygiene and infection control, and upcoming training includes fire safety, challenging behaviour and first aid. The AQAA supplied by the home indicates that two of the four care staff employed at the home have successfully achieved an NVQ Level 2 in Care or equivalent qualification, and that the other two staff are currently working towards such a qualification. The AQAA indicates that the home has relevant employment related policies in place, including on equal opportunities and recruitment and selection. The inspector checked staff employment files, these were found to contain all required documentation, including references, proof of ID and CRB checks, and since the previous inspection the home now has a written record of explanation of any gaps in staff’s employment history. Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 23 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): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the manager is suitably qualified and experienced. EVIDENCE: The home has a full time manager in place, who is registered with the CSCI. They have almost ten years experience of working in the care field, including seven years in a senior capacity. They have achieved an NVQ Level 3 in Care. The manager informed the inspector that they have completed the Registered Managers Award and an NVQ Level 4 in Care, but are still awaiting the certificates for these. Staff and service users informed the inspector that they Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 24 found the manager to be approachable and accessible, and staff were seen to interact with the manager in a relaxed manner. Record keeping in the home was generally of a good standard, and confidential records are stored securely. Staff and service users can access their records as appropriate. According to the AQAA supplied by the home, the home has all necessary policies and procedures in place. Those checked by the inspector, including complaints, admissions and medication were of a satisfactory standard (with the exception of the adult protection procedure as mentioned previously in this report). Care plan reviews, service user meetings and staff meetings all contribute to the quality assurance process within the home. The home issues questionnaires to service users, their relatives and health and social care professionals to gain their feedback on the running of the home. Feedback seen by the inspector on completed surveys contained generally positive comments. One social worker wrote “The manager is helpful and prompt in her responses. The manager and staff team seem calm and capable in meeting at times quite complex needs.” There was evidence that monthly Regulation 26 visits are taking place. Since the last inspection the home has taken steps to ensure that health and safety training is now provided as appropriate, including on infection control and fire safety. Fire extinguishers were situated around the home, these were last serviced in January 2008. The home does not have a fire alarm system installed, but smoke detectors are located around the home. However, one service user showed the inspector their bedroom and made the comment that they did not have a smoke detector fitted in their room, but that they would like one. It was noted that this resident is a smoker, and although the house rules state that nobody should smoke inside the home, there is nevertheless a risk present, and therefore it is required that all bedrooms are fitted with a smoke detector. Those detectors that are in place are checked weekly. The home holds regular fire drills. Fridge/freezer and hot water temperatures are routinely checked. The home has in date safety certificates for PAT testing, electrical installation and gas safety, along with in date employer’s liability insurance cover. Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 5 3 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 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 2 3 3 3 3 3 2 3 Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13 and 15 Requirement The registered person must ensure that individual risk assessments are in place for all service users, covering all areas of potential risk to service users and others. The registered person must ensure that the home supports service users to access appropriate community based social and leisure activities in line with their assessed needs and stated preference. The registered person must ensure that clear and comprehensive records are maintained of all medical appointments, including details of the reason for the appointment, and of any follow up action necessary. The registered person must ensure that all staff undertake appropriate training, which includes an assessment of their competence, before they are able to administer any medications. A record of the training and assessment of the staff competence must be kept DS0000069527.V368917.R01.S.doc Timescale for action 30/09/08 2. YA14 16 30/09/08 3. YA19 13 31/08/08 4. YA20 13 31/08/08 Marula House Version 5.2 Page 27 on the staff members file. 5. YA21 15 The registered person must ensure that the home seeks and records the wishes of service users on the arrangements to be made in the event of their death. The registered person must ensure that the home has an adult protection policy and procedure which is in line with current legislation. The registered person must ensure that a working smoke detector is installed in all bedrooms. 30/09/08 6. YA23 13 30/09/08 7. YA42 13 and 23 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Marula House DS0000069527.V368917.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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