Inspection on 20/08/07 for Mary House

This inspection was carried out on 20th August 2007.

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

The inspector found 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mary House 08/07/09

Mary House 22/07/08

Mary House 05/07/06

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Mary House 490 The Ridge Hastings East Sussex TN34 2RY Lead Inspector Mrs Caroline Johnson Key Unannounced Inspection 20th August 2007 09:50a Mary House DS0000065243.V345901.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 Mary House DS0000065243.V345901.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. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mary House Address 490 The Ridge Hastings East Sussex TN34 2RY 01424 757960 01424 757969 PaulSimmons@marthatrust.org.uk www.marthatrust.org.uk Martha Trust 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) Position Vacant Care Home/nursing 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is eight (8) Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability and/or a physical disability only to be accommodated 27th February 2007 Date of last inspection Brief Description of the Service: Mary House is situated on the outskirts of Hastings with historical Battle a short drive away. It is approximately a fifteen-minute drive to Hastings where there are shops and local amenities. The home is purpose built with all accommodation in single rooms at ground level. The home is registered to accommodate eight adults with learning and physical disabilities and to provide personal and nursing care. The registered providers are Martha Trust, which is a registered `not for profit’ charity, founded in 1983 specifically to care for people with profound disabilities. The home will make CSCI reports available to prospective residents and their relatives/representatives upon request. The gross weekly fee as of May 2006 is £1900 per week. Additional charges are made for toiletries and outings. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection process a site visit was carried out on 20th August 2007. The inspection lasted from 09.50am until 5.45pm. During the inspection there were opportunities to spend time with the newly appointed manager and with three staff members in private. A full tour of the building was carried out. Time was spent observing staff working with residents whilst feeding and enjoying leisure activities. A wide range of documentation was seen including three care plans. In addition records were seen in relation to staff recruitment and training, medication, minutes of meetings menus and fire safety. In advance of the inspection the manager completed an AQAA (annual quality assurance assessment) and information from that document has also been included in this report. Prior to the inspection a range of surveys were sent to the home for distribution to the residents and to their relatives/representatives. Three comment cards were returned from relatives. Overall the result was very positive with comments like ‘Mary House is a god send’ and ‘Mary House offers an holistic care of very acute and specialised needs contained in a very family orientated environment’. One relative whilst stating that Mary House has a ‘happy and caring environment, excellent provision of accommodation and very pleasant and caring staff’ also raised a number of areas where they felt improvements were needed. These related to the need for more therapy and stimulation, regular physio, better oral hygiene, and prompt action when a change in medication is needed. They also stated that they would like to receive more detailed invoices for expenses. Following the inspection attempts were made to contact three relatives but only one was spoken with. This person was very happy with the care and support provided to her relative. Their relative’s placement had been reviewed at regular intervals. They advised that issues raised with the home were dealt with immediately. They also stated that they were happy with the staff levels and with the range of activities available. They had some ideas for the future that they were going to raise at their relative’s annual review. Since the last key inspection held in July 2006 a random inspection was carried out in February 2007. Some progress had been made at that time in addressing the requirements made at the key inspection but some requirements had been repeated. Since the home opened there have been various management arrangements in place and unfortunately this has had a big impact on the development of the service. In June 2007 a new manager was appointed and he will shortly be submitting his application to the Commission for registration as manager. The manager has a nursing Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 6 qualification in learning disabilities and he demonstrated a clear understanding of how the service needs to be developed. What the service does well: What has improved since the last inspection? What they could do better: As a result of this inspection nine requirements and three good practice recommendations were made. Opportunities need to be provided to assist residents in maintaining and developing new skills. If necessary, specialist advice should be sought to assist in this process. Goals set for residents must be achievable and the steps to be taken to achieve these goals must be clearly detailed. Specialist advice should be sought to determine if two of the residents could be more independent in feeding. An action plan needs to be drawn up detailing the action taken by the home to address the recommendations of the recent fire risk assessment. The external management must reinstate monthly-unannounced visits to monitor the conduct of the home. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 7 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. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear information available to assist relatives/professionals in making a choice about appropriate accommodation. EVIDENCE: The statement of purpose includes clear advice and information about the home and the services provided. The manager advised that the document would be updated to include details of his qualifications and experience once he has been registered as manager. There is a pictorial service user guide in place. The manager stated that he would like to develop this document further in an attempt to make it even more user friendly for the client group. There have been no new admissions to the home since the last inspection. One relative who completed the commissions comment cards wrote that ‘the changeover/settling in period for her relative was dealt with in an exemplary manner’. Staff got to know her relative in advance of the move by visiting them at school and in their previous placement. Mary House DS0000065243.V345901.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Significant improvements have been made to the care plans in relation to meeting the physical needs of the residents and this will be of benefit to the residents. However, further work is required on setting appropriate goals for the residents that are achievable and on recording the choices and decisions made by the residents. EVIDENCE: Three care plans were examined in detail. There was detailed information included about the residents and their needs and how they were to be met. Levels of risk had been identified and action required by staff to minimise the risk of accidents/incidents occurring had been included. Reviews of the care arrangements had also been carried out and reports were included. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 11 Levels of communication had also been assessed and advice is included in care plans about how residents communicate whether verbally, with facial gestures or head movements. The evidence of choices and decisions being made by residents is not currently recorded in the daily notes. Goals have been set in relation to social and emotional needs. However, most of the goals that have been set are not easily measurable and achievable. For example, one goal is that the resident will make a simple dish with minimal assistance to offer his peers. Although this resident enjoys the sensory cooking session, they do not eat and even to prepare a simple dish would take a very long time to achieve. The task was not broken down into easily achievable steps. A common goal for many of the residents involved growing a plant of their own. However there was no evidence in the daily notes that they had been involved in this process. Some goals were ongoing rather that time limited but without clear advice for staff on the action to take to encourage/support residents to achieve the goals. The manager agreed that further staff training would be beneficial in this area. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities to participate in a wide range of leisure activities have increased and this has been of benefit to the residents. However, more emphasis needs to be placed on providing opportunities for residents to develop new skills. EVIDENCE: Since the random inspection a therapy assessment has been carried out in relation to each resident and this identifies residents likes and dislikes. Activities residents attend include swimming, tai chi, reflexology, a music entertainer, use of the sensory room, art room and music room and the sensory cooking. Residents also enjoy regular DVDs and videos, trips to places of interest, bowling, theatre, shopping, cafes and the local pub. Some of the residents enjoy being taken to the local church on a regular basis. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 13 Although the range of activities has increased and residents are kept busy and stimulated, nearly all the activities have a leisure theme and there is limited emphasis on educational and personal development aspects. The benefits of activities described are broad, for example, a plan in relation to an art activity could state that the purpose of the activity is to stimulate and to improve the quality of life and whilst these are very important benefits other benefits could be to develop grasping skills or fine finger movements or to encourage choice making in terms of colour. A number of relatives visit on a regular basis and staff reported good relationships with the families of the residents. On the day of inspection three residents had gone swimming. One of the resident’s mums was on holiday in the area so she was also joining her relative on this activity. Staff advised that a new mini-bus has been purchased so that now it is possible to take three residents out at any one time. Since the last inspection sensory cooking has been introduced. Two sessions are held each week and each involves two residents the cook and one member of care staff. Residents are encouraged to participate as much as possible and so far they have enjoyed the results of these sessions. Records are kept detailing progress made. Staff advised that the sessions are working really well. On the day of the inspection there was a cookery session and the residents enjoyed watching the biscuits they had helped to make being taken from the oven. The majority of the residents are peg fed but there is a four-week menu in place for the two residents that do eat. Menus seen were varied and have been adapted for each individual as one resident is diabetic. Two other residents have taste sessions one twice a day and one occasionally. There are clear guidelines in place for this. A record is also kept of alternatives to the menu and how much food has been eaten. Where a resident indicates that they do not want their meal then an alternative is given. However, as on the previous random inspection there were some records showing that the alternative served was either a dessert or a sandwich rather than an alternative main meal. The chef advised that there is a selection of foods available that can be prepared quickly should a resident not like their main meal. As the residents can take a long time to eat their meals staff are advised that the meal can be reheated and one resident has a bowl that is designed to keep food warm. Guidance has been obtained from the Speech and Language therapy department and this is included in care plans. However the guidance is at the rear of the plans and it was not obvious that the recommendations were being followed as in one case it was recommended that the resident use a beaker with a spout but the resident drank from a straw. In relation to another resident it was recommended that staff sit on a perch stool to feed but it was noted that staff stood whilst feeding. One staff member stated that it is easier Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 14 to stand whilst feeding but there was no record seen on file advising of any change to the recommendations. In addition there was a touch cue programme included to support the resident in anticipating and understanding what is happening next. It was not clear if this was used throughout the mealtime. An assessment has yet to be carried out to determine if either of these two residents could participate in feeding themselves. However, it was noted that in the sensory cooking one of these residents was able to stir the cake mixture and a staff member also stated that when finger food was in the vicinity this resident recently helped themselves to the food. Mary House DS0000065243.V345901.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Specialist advice and support is sought where necessary to meet the complex health needs of the residents accommodated. EVIDENCE: Staff seen over the course of the inspection were courteous and treated residents with respect and dignity. The rapport between residents and staff was very good and this was obvious in the vocal sounds and gestures made by residents whenever they were spoken to. The home has recently changed their pharmacy provider and staff reported that the new system is working well. Records seen were in order. It is possible to carry out an audit trail of medication once it is delivered to the home. A record is also kept of all medication handed over to relatives when residents are away on social leave. Records are kept of all medication returned to the pharmacy. The manager advised that they would be changing the location of the medication room as it is felt that ventilation in this area is not as good as it could be. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 16 There was evidence in each of the files seen that a variety of professionals have been involved in assessing and providing specialist advice and support for the residents. The majority of the residents have epilepsy and advice on how to manage this is very detailed and has been drawn up based on protocols from the local Community Learning Disability Service. A Tissue Viability Nurse has provided advice and guidance as required on peg feeds and site management. There is a wide range of equipment in place to meet the individual needs of the residents. The manager advised that they are hoping to get a new walking frame for one resident and this activity will be built into their daily plan. A relative of another resident advised that her relative has been waiting a log time for a walking frame. Residents’ weights are recorded monthly. Oxygen is stored on the premises. In relation to one resident it is stored in their individual bedroom and is on a trolley for ease of access. Specific advice and guidance of storage and use of oxygen is also included in the home’s recent fire risk assessment. Mary House DS0000065243.V345901.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and the plans to reassess the procedure to ensure that it is even better will be of benefit to staff and residents. EVIDENCE: There is a detailed complaint procedure in place, which is displayed within the home. The manager reported that no complaints have been made to the home. Since the last key inspection three complaints have been made to the Commission. In each case the complaint was sent to the provider to investigate and the outcome has been satisfactory. The manager advised that he would like to undertake further work on the complaint process to encourage anyone wishing to complain to use the in-house complaint process in the first instance. Staff spoken with were clear about the home’s complaint procedure. A relative spoken with stated that they have ‘never had any reason to complain’. At the current time there is no user-friendly complaint procedure for the residents and the manager is keen to try to develop a system that could be used by at least some of the residents. There was however, evidence in the daily records that staff respond to residents when they are unhappy. For example residents returned from trips or the environment changed because residents showed signs of distress. Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 18 The policy and procedure in place on the protection of vulnerable adults has been amended since the last inspection and now includes clear advice for staff to follow on the procedure should any form of abuse be suspected. The manager reported that a pova course has been booked for staff to be held on 18 September. At the last inspection of the home a requirement was made that when bruising is noted it should be brought to the attention of the manager and an investigation carried out to identify a possible cause. In addition it was required that if there was any suspicion about how the bruise occurred the matter should be referred to adult protection for possible investigation. Records showed that charts are always carried out when a bruise is noted but the cause is not always recorded. The manager advised that he would design a form that would ensure this information is recorded at all times. Residents’ monies are managed via the head office and there are differing arrangements in place for each resident. It was reported that some residents are in receipt of allowances and some parents receive allowances on behalf of the residents. Records seen of all money spent on behalf of residents are kept by the home and details are sent to the head office. Records were seen in relation to two residents and they were in order. There is no information held within each file detailing how much money is received on behalf of the resident and how it is managed. Mary House DS0000065243.V345901.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has been purpose built and the ample space and variety of communal areas meets the needs of the residents accommodated. The home needs to take action to address the recommendations of the recent fire risk assessment to ensure the safety of the residents and staff. EVIDENCE: A tour of the building was carried out. As the building was purpose built there is ample space for the moving and handling of residents. Within the large lounge there is a large screen cinema surround television. Within this room there is also a table and chairs and a computer for staff use. Just off this room there is a kitchenette for staff and visitors use. A second lounge is also available and there is also a tv in this area. A new aquarium has been purchased and once settled the new plants have settled the residents will be taken to help chose some fish for the tank. The main dining area is next to the Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 20 kitchen. There is a fully equipped bathroom for every two bedrooms and residents have a choice of a bath or shower. Bedrooms have been personalised to reflect the individual tastes and hobbies of the residents. A staff member advised that they are hoping to have seating placed outside each bedroom patio area so that residents can entertain their family and visitors in private. In addition there is a sensory room, art room and a music room. There is a large patio area with seating and a raised garden area is being created to the rear of the property. The area to one side of the property has become very overgrown and needs to be cleared to ensure access from fire escape routes from this part of the building. A detailed fire risk assessment was carried out in July 2007 and the home had received the report of the findings just prior to this inspection. The manager advised that an action plan would now be drawn up detailing all action taken in response to the fire assessment. Records showed that regular tests are carried out on the fire equipment in use in the home and that the equipment is serviced periodically. Fire drills are held at least monthly and the last drill in July involved a full evacuation of the residents. An evaluation of each drill held is not currently carried out. During a tour of the premises it was noted that a couple of doors were propped open. There is a policy in place on infection control, which was last reviewed in October 2005. There is a contract in place for the removal of clinical waste. Mary House DS0000065243.V345901.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The increased training opportunities available to staff will ensure that they are equipped to meet the complex needs of the residents accommodated. Formal supervision sessions need to be reinstated to ensure that staff continue to be supported in their individual roles within the home. EVIDENCE: Staff advised that there are generally five care staff plus one nurse on a morning shift and at minimum four care staff plus one nurse in the afternoon. Records seen in relation to staff recruitment were in order. At minimum two references are obtained in respect of each new applicant and records are kept of identification and of any training courses attended. Staff advised that for the first week of their employment they shadow a more experienced member of staff. During this time they also complete an initial induction to the home. Following this they then commence a more detailed induction package. The manager advised that at the time of inspection five staff were working through their induction to the home. A staff member spoken with advised that they had completed their initial induction but had yet to start their detailed Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 22 induction. All new staff are employed on a three-month probationary period. This can be extended depending on their progress during this time. CRB checks are carried out on all new staff appointed to work in the home. In relation to staff training it was noted that the majority of the staff team have now received training on epilepsy and a further training course has been arranged for new staff. 20 staff have received training on skin integrity, 11 on first aid, 11 basic life support, 8 staff have received training on peg feeding and 19 staff on cerebral palsy. Training has yet to be arranged on feeding and on non-verbal communication. Arrangements have been made for training on infection control, pova and medication. Three staff are currently trained to NVQ level two or above and a further ten staff are currently working towards this qualification. Staff supervisions have not been carried out for some time. However, it was noted that this subject had been raised at the recent nurses meeting and staff had been advised that supervisions must now be reinstated. The manager will also start supervising all the nursing staff. Mary House DS0000065243.V345901.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The appointment of a new manager will hopefully assist in ensuring that staff are given a clear sense of direction to meet the complex needs of the residents. His plans to expand the quality assurance system will also assist in improving care practices. EVIDENCE: At the time of the last key inspection the manager’s position was vacant. Since then there have been various management arrangements in place. However a new manager was appointed in June 2007 and he advised that he would shortly be submitting his application for registration as manager. He is a qualified nurse in Learning Disabilities and has been registered previously in Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 24 other settings. Staff spoken with were pleased that the management arrangements are settled and that they advised that although they have not yet started having formal supervisions they feel supported by the manager. Minutes of a recent house meeting, nurses meeting and of three keyworker meetings were seen. The intention is to hold these meetings at regular intervals to ensure that everyone is up to date with changes in care practices. As part of the home’s quality assurance system satisfaction questionnaires were sent to relatives and visiting professionals in March 2007. The responses to the questionnaires were not on site but the manager advised that the overall response was excellent although a couple of people advised that they felt that communication could be better. As a result of the questionnaires keyworkers now write a monthly letter detailing what residents have been doing during the month and advising of plans for the next month. The manager advised of his intention to introduce a number of audits to monitor the home’s practice in a number of areas including medication and health and safety. Audits of activities and of finances are currently carried out. In advance of the inspection comment cards were sent to the home for distribution to relatives and visiting professionals. Three comment cards were returned from relatives. Overall the result was very positive with comments like ‘Mary House is a god send’ and ‘Mary House offers an holistic care of very acute and specialised needs contained in a very family orientated environment’. One relative whilst stating that Mary House has a ‘happy and caring environment, excellent provision of accommodation and very pleasant and caring staff’ also raised a number of areas where they felt improvements were needed. These related to the need for more therapy and stimulation, regular physio, better oral hygiene, and prompt action when a change in medication is needed. They also stated that they would like to receive more detailed invoices for expenses. Following the inspection attempts were made to contact three relatives but only one was spoken with. This person was very happy with the care and support provided to her relative. Their relative’s placement had been reviewed at regular intervals. They advised that issues raised with the home were dealt with immediately. They also stated that they were happy with the staff levels and with the range of activities available. They had some ideas for the future that they were going to raise at their relative’s annual review. Records of unannounced visits conducted by the external management of the home were not available for inspection. The manager was not aware of any visits having been carried out for this purpose since his employment in June. However he stated that the external managers had visited the home on a number of occasions to meet with him and to discuss his role and responsibilities. Mary House DS0000065243.V345901.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 X 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 2 25 4 26 X 27 4 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X X 2 Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Goals/needs identified in care plans must be specific and include detailed advice for staff on the action to be taken to ensure that goals/needs are met. [This was a requirement of the previous key inspection and random inspections timescales set were 15/10/06 and 15/06/07. It has been partly met.] Timescale for action 30/11/07 2. 3. YA12 YA17 12(1b) 17(2) Sch 4 para 13 4. YA17 14(1a) Opportunities must be 30/12/07 provided for educational and personal development. When a resident refuses the 15/09/07 set meal an alternative meal must be provided. [This was a requirement of the random inspection, timescale 15/04/07]. Assessments must be made 30/11/07 by an appropriately qualified person to determine if two of the residents could develop skills in feeding. [This was a requirement of the previous inspection]. DS0000065243.V345901.R01.S.doc Version 5.2 Page 27 Mary House 5. YA24 23(4) 6. YA35 18(1ci) 7. 8. 9. YA36 YA37 YA43 18(2a) 9(1) 26 In relation to fire safety, an action plan must be drawn up detailing the action taken to address all the recommendations made as a result of the recent fire risk assessment. This must include reference to the overgrown area to the side of the property, the propping open of fire doors and to the need to evaluate fire drills. In addition to all mandatory training staff must receive training in the following areas: - feeding and nonverbal communication. [This was a requirement of the previous key and random inspection and it has been partly met. Timescales set were 30/11/06 and 15/05/07] The registered person must ensure that all staff receive regular supervision. The acting manager must apply for registration as manager. Arrangements must be made to ensure that the responsible individual or a representative on his behalf visits the home on a monthly basis, unannounced and that a report of the outcome of the visit is given to the manager and available for inspection. 15/10/07 30/12/07 30/09/07 30/09/07 15/09/07 Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Daily notes held in respect of each individual should include the action taken by staff to meet the goals/needs identified in care plans. A copy of the guidelines for feeding should be kept in the dining room for reference. Information about each resident’s financial entitlements should be kept in their individual care plan along with information about how it is to be managed. 2. 3. YA17 YA23 Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Mary House DS0000065243.V345901.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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