Inspection on 05/07/06 for Mary House

This inspection was carried out on 5th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 16 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 20/08/07

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 Caroline Johnson Key Unannounced Inspection 5th July 2006 09:30 Mary House DS0000065243.V296017.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.V296017.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.V296017.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 01304 615462 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) Martha Trust Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Mary House DS0000065243.V296017.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 N/A 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 approximatley a fifteen minute drive to Hastings where there are shops and amenitites. 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. The home is registered 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.V296017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection undertaken in the home since the home opened in November 2005. As part of the inspection process an unannounced site visit was carried out on 5 July 2006 and it lasted from 09.30am until 6.30pm. During the inspection there was an opportunity to spend time in the lounge with all of the residents and to observe the evening meal being served to one of the residents. There was also an opportunity to speak with two of the nursing staff and two care staff in private. A wide range of records were examined including the care plans for two residents and record keeping held in relation to staff recruitment, medication, complaints, health and safety, menus and fire safety. A full tour of the building was also undertaken. Shortly after the home opened the registered manager resigned from her position as manager. Since then the Director of Nursing has been working as an acting manager in the home. The management position has been advertised and it is hoped that a suitable manager will be appointed in due course. The Director of Nursing was working in the head office on the day of inspection but the Deputy Director joined the inspection for the majority of the day. What the service does well: What has improved since the last inspection? Not applicable Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 6 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. Mary House DS0000065243.V296017.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 Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose needs to be updated and a service user guide drawn up so that all prospective residents and their relatives are clear about the service provided in the home. The home should keep all records relating to pre admission assessments in the home and available for inspection. EVIDENCE: The statement of purpose in place was the document that was put in place when the home first opened. However, the registered manager has resigned from her position since then and the statement of purpose needs to be updated to reflect the changes. At the time of inspection there was no service user guide in place. It was reported that the home are working on this document and gathering photos. Terms and conditions of residence could not be seen, as they were located at the head office. A pre admission assessment was seen in relation to one resident who is due to move to the home. The home had carried out an assessment of needs and the prospective resident’s mother had also provided a very detailed report for the home. It was not clear if an educational report had been obtained. Staff reported that there was a transition plan in place but due to unforeseen Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 9 problems the moving in date had changed. The prospective resident had visited the home on a number of occasions and staff were confident that during these visits there was an interim care plan and daily records were recorded, but these could not be located. It was thought that copies of the terms and conditions of residence are held at the head office. Mary House DS0000065243.V296017.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Goals/needs identified in care plans should be more specific detailing the action required by staff to ensure that they can be met. Daily records should include more detailed information about the work undertaken with residents and more detailed records would then make the task of evaluating progress with goals much easier. EVIDENCE: Two care plans were examined in detail. Each resident’s needs had been assessed and there were a number of goals/needs identified. In most cases the goals identified were very broad and it was not easy to identify what the expected outcomes were meant to be. Daily record notes referred to feeds and baths and there was no reference to progress with goals. In relation to one resident there was a goal in place to ensure that a letter was sent on her behalf to her relatives on a weekly basis. There was no record to indicate that this had been carried out. However, when speaking with a member of staff they stated that a letter is sent on a weekly basis. There were a number of risk Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 11 assessments in place along with the action to be taken by staff to minimise the risk of accidents. Staff stated that as they are getting to know the residents they are learning how residents make basic choices and decisions. Examples include facial expressions when particular types of music are played. For another they will look to the right when they are happy but will look to the left or straight ahead and grimace when unhappy. Mary House DS0000065243.V296017.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. If the home were to assess each of the residents’ educational and leisure needs they could then plan activities in advance to ensure that individual needs could be met. The home has excellent equipment in place to meet the needs of residents with profound disabilities. Training needs to be provided so that staff and residents can make the best use of the equipment. EVIDENCE: One member of staff has been delegated as activity co-ordinator for the home. Staff advised that in addition to physiotherapy and reflexology residents have a tai-chi session every other week. Although some sessions are planned the majority of sessions are arranged spontaneously depending on the staff levels and the weather. There is an art room, which is also used for sensory sessions. There is also a music room which houses an organ, a keyboard, sound pads and sound beams. Staff reported that whilst they have some knowledge of how the equipment works they do not know how to achieve the most out of it. A local vicar visits on a regular basis and he plays the guitar and sings hymns. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 13 There is a large paddling pool in the patio area and staff reported that two of the residents enjoy spending time in it with support during the hot weather. External activities include trips to the local pub, to the seafront and to garden centres. In addition a couple of the residents are taken to the local church on a regular basis. Some of the residents attend swimming at a hydro pool on a rotational basis. Staff reported that they had recently taken a couple of residents to Battle to visit Yesterday’s World and that they had also been on a trip to Drusilla’s zoo. Staff stated that they now feel more confident taking residents out and that the number of activities has increased in recent weeks. Although the range of activities is increasing the home have not yet carried out an assessment of each residents educational and leisure needs. The home had arranged for an African drummers group to come into the home for one of the resident’s birthday parties. In February the home sent a newsletter to parents advising them of progress made in the home since the home opened. In the newsletter it stated that a newsletter would be sent regularly but no further newsletters have been sent. All of the residents have regular contact with their relatives and spend some weekends each month away from the home. There is one minibus for use by residents but the bus can only carry two residents at any one time. The home are hoping to purchase another. Annual holidays are included in the residential fee. All but one of the residents are peg fed (feeds by gastric tube, percutaneous enteric feeds). In relation to the one resident that has food, there is a threeweek menu in place showing the food to be provided. It was reported that the menu is flexible to fit in with the needs of the resident. Records are not kept of the actual meals served. Food is freshly prepared each day for the main meal and the cook prepares the evening meal so that care staff just need to heat it up. On the day of inspection the main meal was poached salmon and vegetables and the evening meal was a broccoli and cauliflower cheese bake. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is essential that staff receive training on epilepsy as a matter of urgency so that they can effectively manage the needs of the residents in the home. EVIDENCE: Staff spoken with during the inspection confirmed that they support residents to attend healthcare appointments as required. Records seen in relation to medication administered to residents were in order. At the time of inspection the fridge for storing some medications was not working but a new fridge had been ordered and was delivered during the course of the inspection. Some of the resident’s feeds were stored in the art room as space in the treatment room is limited. It was advised that this is a temporary measure until more suitable storage is identified. Residents are weighed on a regular basis. Although there are qualified nursing staff it was not clear if they have received recent training on medication. In addition nursing staff are general trained and have limited experience of working with adults with learning disabilities. All of the residents have epilepsy and it is essential that all staff receive Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 15 training on epilepsy, causation, types and management and on the medication in use in the home for epilepsy. At the time of writing this report written confirmation had been received that the home had written to their pharmacist regarding arranging appropriate training. In relation to one of the residents one of the goals identified is to control their epilepsy. Staff reported that the gp is involved and that alterations have been made to the medication to try to achieve this goal. A physiotherapist visits the home weekly to see all the residents. There is a programme of exercises in place for each resident and staff ensure that the exercises are carried out as recommended. A reflexologist is also employed by the Trust to visit the home twice a month. It was reported that the Community Learning Disabilities team carried out continence assessments on all the residents. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff should receive training on adult protection and prevention of abuse so that they are aware of the steps to be followed in the event of an allegation of abuse. EVIDENCE: There is a detailed complaint procedure in place. The complaints book is located at the entrance lobby to the home. This means that if anyone were to write a complaint in the book it would not be confidential. There were no complaints recorded since the home opened and no formal complaints have been made to the Commission. There is a procedure in place on adult protection and prevention of abuse. The procedure should be amended to make it clearer that in the event of an allegation the home should take direction from Social Services on any action to be taken rather than starting their own investigations. It was reported that a member of staff from the home’s sister home in Deal has attended a `train the trainer’ course on the subject of adult protection and arrangements will now be made to cascade training on the subject to all staff in the home. There is a restraint policy in place. However, the policy does not refer to restraint in the widest sense. For example to recognise that residents are restrained all the time by virtue of lap straps on wheelchairs and that very limited opportunities are made available for residents to have time out of their wheelchairs whether it be on the floor or on beanbags. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 17 Residents’ finances were discussed in detail and records were seen in relation to two residents. There are different arrangements in place for each of the residents. Detailed records were seen and they were in order. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The building has been specifically designed with space in mind and to meet the needs of adults with physical disabilities. Residents have specialist equipment to meet their individual needs. The home needs to start having fire drills to ensure that staff are aware of the action to be taken in the event of a fire. EVIDENCE: The building has been designed with space in mind. In addition to a very large lounge area, there is a large dining room. In the lounge there is a cinema type television with surround sound. Activity rooms include an art room, and a music room. For every two bedrooms there is a shared bathroom. Each bathroom includes a specialist bath and shower trolleys are also provided. Where applicable there is a specialist commode in place. Specialist seating is provided in the lounge areas. There are hoist facilities and standing frames. Bedrooms have been personalised and include overhead hoists. Staff advised that residents’ parents have been involved providing information about the most appropriate choice of décor for bedrooms as a way of assisting their relatives to settle into the home. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 19 The rear of the property has yet to be landscaped. However, there is a large patio area, which has been well used by the residents over the summer. In the centre of the patio area there is a fountain. There is a fire risk assessment in place. Records showed that regular checks are made on the home fire safety equipment and that alarms and lights are tested in line with the home’s policy. All equipment is serviced on a quarterly basis. Fire instruction training was provided to staff in February 2006. Fire drills have not been undertaken since the home opened. The home’s policy is that drills would be undertaken every six months. Residents’ washing is carried out on an individual basis. There are two washing machines and two tumble driers. There is a sluice room. All areas of the home were clean and there were no unpleasant odours. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is essential that staff receive training to ensure that they can meet the complex needs of the residents accommodated. The home also needs to draw up a plan to ensure that care staff are given the opportunity to undertake training at NVQ level two or above. EVIDENCE: There has been a fairly high turnover in the staff team since the home opened. The reasons for the staff turnover were discussed. It was noted that no staff have left the home since February 2006. The rotas supplied showed that there is a qualified nurse on duty throughout the day and night. In addition at night there is a member of care staff and through the day there are either three or four care staff on duty along with a cook, domestic, maintenance person and an administrator. All ancillary staff are employed on a part-time basis. It was reported that it is not always possible to take residents out when there are only four staff on duty. Staff advised that when they started in post their first week was spent observing practice and there was no hands on care. During this time they had Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 21 a short induction to the home, which included information about fire safety, use of hoist and equipment, and there was time to read through the care plans. It was also reported that the home also has an induction package that is linked to Skills for Care but that staff appointed in recent months have not yet started on the induction package. A new training co-ordinator has been appointed and his first task is to check through each staff file to see what courses staff have attended and to sort out each individual’s training priorities. Eight staff have received training on fire safety. Twelve staff had received training on moving and handling and it was reported that moving and handling training would be provided to a number of staff the day following the inspection. It is evident that a number of training courses need to be arranged. Areas to be covered include: - epilepsy, tissue viability, cerebral palsy, non-verbal communication, feeding and peg feeding. Staff spoken with advised that a nutritionist visited the home and provided some information to staff on diets. A Speech and Language therapist is to provide training for staff in relation to feeding one resident. All staff spoken with stated that they are keen to attend training courses. None of the qualified staff have a background in learning disabilities. It was not clear if any of the care staff have an NVQ. Once this has been established arrangements will be made for all care staff to attend relevant courses. Recruitment records were seen in relation to three staff employed to work in the home. In each case there was a completed application form and a minimum of two references. CRB checks had been obtained for two staff, in one case the home were awaiting a full CRB but a pova first check had been obtained. Details of staff qualifications were recorded in some of the files but staff had yet to bring in their certificates. Supervision records were locked away and the staff on duty did not have access to the key so they will be examined at the next inspection of the home. The Director of Nursing and the deputy director provide supervision to all nursing staff and the nursing staff then provide supervision to care staff. Some of the staff spoken with stated that supervision is not currently every six weeks but everyone had had at least one supervision since they started in post. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is essential that a manager be appointed to manage the home. If there is to be any further delays in recruiting a suitable manager then the organisation must use an agency manager. The organisation must introduce a quality assurance system to review and build upon the quality of the care provided in the home. EVIDENCE: Since the home opened the registered manager resigned from her management position. The Director of Nursing for the Trust has stepped in in the interim until a suitable manager has been appointed. It was reported that interviews for the position were imminent and that should they be unable to fill the position following interview they would use a recruitment agency until a suitable manager can be recruited. Staff reported that the Director of Nursing is in the home most days and that she is approachable and her `door is always Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 23 open’. She is good at ensuring that staff morale remains good. Although all staff were generally happy with the current management arrangements they stated that they were looking forward to having a registered manager in place. In relation to quality assurance the home has yet to introduce a tool to measure the quality of the care provided in the home. There is no annual development plan in place. It was reported that the Trust would be starting to carry out financial audits the week following the inspection. Satisfaction questionnaires have yet to be distributed to the relatives of the residents to seek their views on the quality of the care provided in the home. In relation to health and safety there were a range of certificates in place to show that equipment is serviced regularly. Hot water temperatures tested during the inspection were within agreed safety limitations. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 4 26 4 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 3 x Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 25 N/A 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 YA1 Regulation 6(a,b) Requirement The statement of purpose must be amended to reflect the changes in the management team. A service user guide must be drawn up which must include a copy of the home’s terms and conditions of residence. 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. A detailed assessment must be carried out in relation to each resident’s educational and leisure needs and following this a plan must be put in place to meet the needs identified. A record must be kept of the actual meals served in the home. Alternative arrangements must be made for the storage for residents’ peg feeds. Staff must receive training on the medication in use in the home with particular emphasis on medication used to control epilepsy. All staff must receive training on DS0000065243.V296017.R01.S.doc Timescale for action 15/10/06 2. YA1 5(1,2,3) 15/10/06 3. YA6 15 15/10/06 4. YA12 12(1b), 16(2m,n) 30/10/06 5. 6. 7. YA17 YA20 YA20 17(2) Sch 4 para 13 13(2) 13(2) 30/09/06 15/10/06 30/10/06 8. YA23 13(6) 30/10/06 Page 26 Mary House Version 5.2 9. 10. YA24 YA32 23(4e) 18(1ci) 11. YA34 19 Sch 2 para 4 18(1ci) 12. YA35 13. YA35 18(1ci) 14. 15. 16. YA36 YA37 YA39 18(2) 9(1) 24(1,3) adult protection and prevention of abuse. Fire drills must be held to ensure that staff know the procedure to be followed in the event of a fire. The home must produce a plan to show how they intend to have at least 50 of the care staff team trained to NVQ level two or above. Each staff file must include copies of certificates for any courses attended or qualifications achieved. Arrangements must be made for all staff to receive an appropriate induction to the home that is linked to Skills for Care. In addition to all mandatory training staff must receive training in the following areas: epilepsy, tissue viability, peg feeding, cerebral palsy, feeding and non-verbal communication All staff must receive supervision at least six times a year. The organisation must appoint a suitably qualified manager to run the home. Satisfaction questionnaires must be circulated to relatives and all relevant professionals involved in the home. 15/10/06 30/09/06 15/10/06 30/10/06 30/11/06 30/11/06 15/10/06 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations All information recorded as part of the home’s preadmission assessment should be available for inspection. DS0000065243.V296017.R01.S.doc Version 5.2 Page 27 Mary House 2. 3. 4. YA6 YA22 YA23 5. 6. 7. YA23 YA36 YA39 Daily notes held in respect of each individual should include the action taken by staff to meet the goals/needs identified in care plans. The complaints procedure should be displayed prominently but complaint records should be stored securely to ensure confidentiality. The adult protection procedure should be amended to make it clearer that in the event of an allegation, advice should be sought from Social Services on the action to be taken. The home’s policy on restraint should be amended to explore the subject in more detail with particular reference to the client group catered for at Mary House. A chart should be used to show planned dates for staff supervision and if the supervision has actually happened. The organisation should draw up an annual development plan for the home. Mary House DS0000065243.V296017.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mary House DS0000065243.V296017.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. 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. 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