Inspection on 22/07/08 for Mary House

This inspection was carried out on 22nd July 2008.

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

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

Other inspections for this house

Mary House 08/07/09

Mary House 20/08/07

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 08/11/2008.

CARE HOME ADULTS 18-65 Mary House 490 The Ridge Hastings East Sussex TN34 2RY Lead Inspector Caroline Johnson Unannounced Inspection 22nd July 2008 09:45 Mary House DS0000065243.V363704.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.V363704.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.V363704.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) Mr Paul John Simmons Care Home 8 Category(ies) of Learning disability (0) registration, with number of places Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing (N) only - service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability (LD) The maximum number of service users to be accommodated is 8. Date of last inspection 20th August 2007 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 July 2008 ranges from £1,883 to £1,969 per week. Additional charges are made for toiletries and outings. Mary House DS0000065243.V363704.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 2 stars. This means that the people who use this service experience good quality outcomes. For the purpose of this report the people living at Mary House will be referred to as ‘residents’. As part of the inspection process a site visit was carried out on 22nd July 2008 and it lasted from 9.45 until 5.00pm. The registered manager facilitated the inspection. Over the course of the inspection there was an opportunity to meet with all the residents and some time was spent observing residents in their surroundings. In addition time was spent with two members of staff in private. A full tour of the home was undertaken. Three care plans were examined in detail. In addition records seen included; staff rotas, training, medication, menus, health and safety, quality assurance and leisure activities. In advance of the inspection process a range of surveys were sent to the home for them to distribute. Five surveys were returned, one from a service user, one from a healthcare professional and three from staff at the home. Overall the response to the surveys was very positive with comments such as: • ‘Provides excellent care for those with complex learning disability/physical disability. A competent and reliable service for the client group. Rare to find nowadays. Fantastic environment and professional staff who seem very committed’. ‘I feel it provides a really good environment for young adults to reach their goals and enjoy their lives while having a good support system around them’. ‘We are providing a high standard of care, but I believe with the improvements I have already written being implemented ‘(that included ‘better funding, more equipment and better staff wages’) ‘we could improve the standard of care even further’. • • At the time of inspection work was underway to build an extension to Mary House. The extension will include four extra bedrooms, additional lounge and kitchen facilities and a hydrotherapy pool. It is expected that this work will be completed in the summer of 2009. 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. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home is introducing person centred planning for all residents, which means that care will be tailored more to individual needs. The quality of care planning has improved and information provided is much more detailed. Each resident now has an individual goal that they are working to achieve. Extensive work has been carried out with the Speech and Language Team to work on ways of improving communication with individual residents and on identifying the wishes of the residents. Very good progress has been made in relation to supporting one resident to become more independent with feeding. The home has employed a physiotherapist who visits regularly and provides advice and support. A couple of the staff team have completed training on ‘Sensory thinking’ and this training is now being cascaded to the rest of the staff team. A wide range of sensory equipment has just been purchased and the sensory room is currently being revamped. The garden to the rear of the property has been developed and there is now a clear walkway around the garden with extensive plants and shrubs. A raised bed has been installed but further work will be carried out on this to make it more user friendly. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 7 Family forum days are now being held on a quarterly basis and these are an opportunity for relatives to visit, meet with staff, share their views and hear from the manager and the senior management about any changes planned for the home and the wider organisation. What they could do better: 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.V363704.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.V363704.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): 1,2,3,4,5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their representatives are provided with detailed information about the home. EVIDENCE: There is a very detailed statement of purpose in place, which was updated following the registration of the manager. In addition there is a service user guide in place, which includes photos of the residents doing various activities both in the house and in the local community. As two of the residents have a visual impairment the manager agreed it would be good to have an audio version of the guide in place. There is a very detailed terms and conditions of residence in place. The document needs to be updated to include the correct address for the Commission. Records seen in relation to a resident admitted to the home showed that the resident had at least four visits prior to moving to the home. A detailed assessment had been carried out of their individual needs and abilities and a Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 10 range of information was also obtained from the residents’ family and from other professionals that had been involved in their care previously. Once the resident moved into the home there were regular reviews carried out. Records showed a good level of communication between the home and the relatives of the resident. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of the support plans in place is very good and with better record keeping in some areas this will be enhanced even further. EVIDENCE: Since the last inspection work is underway to introduce person centre planning (PCP). PCP meetings have replaced Keyworker meetings. The manager has provided training for staff on the concept and to date three PCP maps have been drawn up in relation to three residents. The maps show information about the resident’s past, what their current needs are, their hopes and dreams and information about the people that are important to them. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 12 Three care plans were examined on this occasion. There was clear information about the resident’s needs and how they were to be met. Information was also provided on how best to communication with each resident. Goals have been identified for all of the residents. At the time of inspection work had not started on all the goals but records seen in relation to some of the goals that residents are working on were detailed. One resident is learning to turn the pages in his book. The long-term aim is for the resident to be able to look through books independently. The support to be provided by staff to assist the resident with their goal is clearly detailed and a chart is in place to show all progress with this goal. Risk assessments have been carried out in relation to all aspects of caring for each resident. Those seen were up to date and included very detailed advice. Where a particular condition has been diagnosed information is provided for example in relation to epilepsy there is detailed information about the type of epilepsy experience by each individual and how to respond should they experience a seizure. Daily record sheets are used to record information about each resident. One side of the sheet is used to record information about a resident’s physical and health needs. The rear of the sheet is used to record information about activities that they have participated in over the course of the day. Record keeping in relation to this is not to the same standard as all other records in the care plan. For example it will state that a resident has spent time in the art room but not what they were doing or the extent to which they participated in the activity. Residents are making some choices throughout the day but the home needs to find a way of demonstrating more clearly via record keeping the choices made. Mary House DS0000065243.V363704.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): 11,12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a good range of varied and stimulating activities to meet their individual needs. EVIDENCE: Each keyworker sits down once a month with their key client and devises a letter to be sent to the relatives of the resident telling them about the activities that their son/daughter have participated in over the previous month. Staff stated that feedback from relatives has been very good and relatives enjoy receiving the letters. A staff member spoken with stated that her key client sits with her when she writes the monthly letter to his mum and he laughs when she reads it to him. This is his way of indicating that he is happy with the contents. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 14 There is an individual programme of activities in place for each resident. Timetables are monitored by the Trust’s activity co-ordinator. Activities include swimming, music therapy, reflexology, sensory cooking and music gym. Residents take it in turn to go swimming and they use a hydro pool in Deal. Two to three residents go one day a week. The manager advised that he is continuing to look for a hydro pool more locally that has suitable equipment in place. Once the home’s hydro pool is up and running residents will have access to this as often as they choose. Two residents also go to the Decoda music gym in Hastings. Two permanent places have been arranged and residents take it in turn to go each week. The home has the benefit of a fully equipped art room and music room. In addition a wide range of new sensory equipment just been purchased and the sensory area is being reorganised to fit the equipment. The manager advised that two staff have recently attended training on using sensory equipment (sensory thinking) and they are now cascading this training to the rest of the staff team. Up to four residents are taken to Church each week and in addition the local Vicar visits periodically and he sings and plays the guitar for the residents. The home continues to look for interesting activities for the residents and at the time of inspection they were exploring the possibility of carriage riding. One of the residents enjoys talking magazines and books. All of the residents enjoyed an annual holiday this year. They went in two groups of four. The manager advised that options for next year are already being explored, as it is difficult to find places with the right equipment provided. Next year they will go in groups of two. There are two minibuses for resident use. One can accommodate two residents and the second three residents. Since the last inspection the home has sought specialist advice from both the speech and language therapist and an occupational therapist in relation to two of the residents becoming more independent with feeding. This has been particularly successful in relation to one of the residents. There are now guidelines in place for this resident in relation to finger feeding foods and the resident also uses adapted cutlery for feeding herself. During the inspection the resident was observed drinking her drink independently. A further assessment is to be carried out in relation to a third resident. There is a four-week menu in place, which is varied and provides a choice of meal. A new format has been devised to record details of the actual meals Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 15 served and the quantity of the meal. Discussion was had about the use of photography to assist residents in making decisions about menu choices. In addition to guidelines in place in care plans in relation to eating and drinking, these guidelines are now also in the kitchen area and in relation to one resident there are photos showing the correct way to feed the resident. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place ensure that the healthcare needs of the residents are met. EVIDENCE: Staff seen over the course of the inspection were courteous and treated residents with respect and dignity. There was a good rapport between residents and staff and staff included residents as far as it was possible to in all tasks that they were carrying out. The temperature of the room used to house medication is monitored daily and records showed that the temperature is just satisfactory. Ideally all medication should be stored at a lower temperature. The manager advised they have done as much as they can to lower the temperature. Once the new build is completed there will be an additional medication room and all medication may have to be stored there. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 17 Records seen showing medication administered to residents were generally in order. There were detailed guidelines in place in respect of the management of medication in relation to epilepsy and the management of enteral feeds. Records are kept of all medication provided and returned for residents’ social leave. Each resident has a health action plan in place that is reviewed regularly. Record keeping is in place to show that residents’ weights are monitored regularly. Detailed records are kept of all medical appointments. The home has recently employed a physiotherapist to work part-time in the home and she is already providing very good advice and support to the staff team. Each resident has a list of daily exercises to be undertaken. There is a designated member of staff who works with the physiotherapist and is available to cascade this training to the staff team and families. As part of care planning and activity planning, there are arrangements in place to ensure that residents have their position changed at regular intervals throughout the day. Time is spent on beanbags. One resident has a day bed, another resident has assisted walking and all residents have specialist seating. The manager advised that fund raising is underway to purchase a standing frame for one resident. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 18 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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are procedures in place to ensure that anyone wishing to make a complaint can do so. EVIDENCE: The manager advised that in relation to complaints there is an open door policy. He has only received one complaint since the last inspection. The details of the concerns were clear and the investigation and outcome was well documented. No complaints have been made to the Commission about this service. There is a simplified version of the complaints procedure in the service user guide. The manager advised that they are continuing to work with the speech and language therapist to try to develop a more meaningful complaint procedure for the residents. It was noted during the inspection that when residents were preparing to go for a walk one of the residents made a number of vocalisations showing that he was unhappy. Staff perceived that the resident did not want to go for a walk and when he was taken from his wheelchair he appeared happier. Records were seen in relation to the management of two residents’ finances and all records seen were in order. The home has a policy in place on the protection of vulnerable adults. The majority of the staff team have received training on the subject. A staff member spoken with was clear about what action they would do if they suspected abuse. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 19 Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 20 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): 24,25,26,27,28,30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is very well maintained and the standard of décor is of a high quality. EVIDENCE: There is a range of areas for communal use. These include an art room, a music room and a sensory room. Residents’ artwork is on display in art room. One of the residents has a computer and this is stored in the music room. As stated previously the sensory was being altered at the time of inspection. There are two lounge areas. One very large lounge has a projector screen with cinema surround sound. In the second lounge area there is a smaller television and there is also an aquarium. From the second lounge there is access to the dining area. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 21 Bedrooms have been personalised to reflect the individual tastes and interests of the residents. Bedrooms are very homely and wherever possible residents and where appropriate their relatives have been involved in the choice of décor. Outside each bedroom there is a patio area and each area has been designed differently with a good variety of plants to make the area look and feel very homely. There is a fully equipped bathroom for every two bedrooms. Residents are able to choose between having a shower or bath. There is a central patio area, which has a water feature and residents enjoy spending time in this area, weather permitting. To the rear of the property work has been ongoing to create a very attractive garden area with a very good variety of different and interesting plants and features. A raised bench was installed to use as a raised flower bed so that residents could get involved in gardening but further work is required to make this more user friendly. One of the nursing staff has responsibility for ensuring that appropriate infection control measures are in place in the home. The home’s COSHH folder is also kept up to date. A cleaner is employed 25 hours a week and she has a cleaning schedule to follow. There are clear lines of responsibility in relation to whose role it is to clean equipment in use in the home. The maintenance man ensures that all overhead hoists are kept clean and care staff have responsibility for ensuring that wheelchairs are cleaned regularly. All areas of the home seen during the inspection were clean. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although staff are generally well trained in many areas, inadequate staff training in some areas could compromise the quality of care provided for residents. EVIDENCE: The rota shows that there are a minimum of five care staff on duty and one nurse. If this is not the case agency staff are used to increase the staff level. The manager’s hours are in addition to this. All nurses have an administration day once a week to ensure that they keep up to date with staff supervisions, healthcare appointments with residents and keep care plans up to date. There is one nurse and one care staff on duty at night. Records seen in relation to recruitment were thorough and appropriate measures are in place to ensure that all checks are carried out prior to appointment. At the time of inspection there was one nurse vacancy. The Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 23 manager advised that he advertised for the post but didn’t appoint. Further attempts will be made to fill this position. Nursing staff are covering the vacant hours. AQAA shows that out of 18 care staff, 11 staff have completed NVQ level 2 or above and five are studying for the qualification. An additional three of the four bank staff used have and NVQ. The manager confirmed that one of the nursing staff has recently completed the Assessors Award. It was reported that the home has started having ‘lunchtime seminars’, the first topic being ‘Sensory Thinking’. In addition the manager runs a makaton workshop once a month. A requirement was made at the last inspection that in addition to all mandatory training all staff must receive training on feeding and on non-verbal communication. The speech and language team (SALT) have provided advice and support to the staff team in relation to feeding. In addition to the makaton training the home are also taking part of a pilot study with the Eastbourne SALT in relation to Intensive Communication with clients with profound learning disabilities. In relation to mandatory training, records showed that seven of the staff team have received training on communication, six on emergency first aid, ten on epilepsy. All of the staff team received training on fire safety, five on food safety, five on health and safety, eleven on infection control, eighteen on moving and handling and pova. Seventeen of the staff team completed a course on cerebral palsy in May 2007. The manager advised that the training co-ordinator is currently on sick leave but that he hopes that arrangements would be made to deal with all shortfalls in training in the near future. The staff matrix does not include details of training that nursing staff would be expected to attend. Individual staff records would show details of this but these were not examined on this occasion. Records seen in relation to staff supervision showed that staff have received supervision at regular intervals. In relation to the staff spoken with during the inspection one staff member stated that they receive a supervision session every six weeks. The second carer said that they have had very few supervision sessions. The manager agreed to look into this further as his understanding was that all staff receive supervision regularly. All staff receive an annual appraisal of their performance. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run well in the interest of the residents accommodated. More robust quality assurance monitoring could enhance this even further. EVIDENCE: Since the last inspection the manager has been successful in his application for registration. In addition to being a Registered Nurse (RNMH) he has also completed NVQ level four and has worked for several years at a management level. The manager advised that he received regular supervision from his line Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 25 manager and he has also had an annual appraisal. He stated that he feels well supported in the role. Records showed that staff meetings are held monthly. All staff are given clear information about changes in care practices and they are encouraged to share their views. Staff spoken with stated that they find the meetings helpful. Nursing staff also have regular meetings, which were also well documented. As part of the home’s quality assurance there is now a family forum day, which is to be held quarterly. So far one meeting has been held and a second meeting is planned to be held in August. The manager stated that the first meeting was very successful, there was a very good attendance and there were detailed minutes in place in relation to the outcome. The meeting was a good opportunity to keep everyone up to date with the plans for the extension to Mary House. Relatives could also send in agenda items. In addition to this there is now a quarterly newsletter. This will be sent to relatives and a copy will also be on display at the entrance of the home. A manager from another service run by Martha Trust visits the home once a month unannounced to report on the conduct of the home. The manager usually spends a whole day in the home, examines a care plan, meets with staff and residents and examines a range of documentation. Reports were in place for the first three months of the year. The manager confirmed that there was no report carried out in April. Visits were conducted in May and June but the manager has yet to receive the report of these visits. The report form does not have space to record the name of the person that carried out the visit. In addition although time is spent with staff there is no space to record staff views. The home has recently introduced auditing of care plans. Records of a recent audit were examined and it was noted that it mainly referred to statistics rather than outcomes. The manager advised that that been the remit given but that he agreed it would also be good to look at outcomes for residents. As part of the inspection process a range of survey forms were sent to the home to distribute to residents, staff and visiting health professionals. Five surveys were returned, one from a service user, one from a healthcare professional and three from staff at the home. Overall the response to the surveys was very positive with comments such as • ‘Provides excellent care for those with complex learning disability/physical disability. A competent and reliable service for the client group. Rare to find nowadays. Fantastic environment and professional staff who seem very committed’. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 26 • ‘I feel it provides a really good environment for young adults to reach their goals and enjoy their lives while having a good support system around them’. ‘We are providing a high standard of care, but I believe with the improvements I have already written being implemented ‘(that included ‘better funding, more equipment and better staff wages’) ‘we could improve the standard of care even further’. • Records seen in relation to health and safety arrangements are thorough. All staff receive regular training in fire safety. Fire alarms are tested weekly and lights monthly. Fire drills are now held regularly and a detailed evaluation is kept of each drill. There are records in place to show that all equipment is tested regularly. Hot water temperatures are checked every three months, monthly vehicle checks are carried out and portable appliances are checked annually. The fire risk assessment has been updated recently and the one recommendation made has been addressed. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 27 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 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 28 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 YA35 Regulation 18(1) Requirement Timescale for action 15/10/08 2. YA39 26 The registered person must ensure that staff receive appropriate training to undertake their roles and the training provided is updated regularly. The registered person must 30/09/08 ensure that a copy of all Regulation 26 reports is in the home and made available for inspection. 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. Refer to Standard YA6 YA7 Good Practice Recommendations Daily records should be used to demonstrate more clearly the work carried out with residents. The home should find ways of demonstrating more clearly how residents are making choices and decisions. Mary House DS0000065243.V363704.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone 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.V363704.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!