CARE HOME ADULTS 18-65
Mary & Joseph Palmerston Street Ancoats Manchester M12 6PT Lead Inspector
Steve O`Connor Unannounced Inspection 16th December 2005 11:00 Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 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 & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 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 & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Mary & Joseph Address Palmerston Street Ancoats Manchester M12 6PT 0161 273 6881 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) The Joseph Cox Charity Bernard Joseph Cox Care Home 41 Category(ies) of Past or present alcohol dependence (0), Mental registration, with number disorder, excluding learning disability or of places dementia (0) Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users must be male only All service users require care by reason of past or present alcohol dependence and may additionally require care by reason of mental disorder. The home is registered for a maximum of 41 services users. Staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum `Care Staffing in Care Homes for Younger Adults`. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 31st August 2005 5. Date of last inspection Brief Description of the Service: Mary and Joseph House is a care home providing 24-hour residential care and accommodation for 41 men who are alcohol dependent and may also have mental health problems. The home is situated close to Manchester City Centre, near to local amenities and public transport links. The home was purpose built to meet the needs of the client group and is sited in a mixed residential and commercial area. Bedroom accommodation is provided over the ground and first floors. All bedrooms are single with hand washbasins and there are a number of selfcontained flats. The building is accessible for people who use wheelchairs and accommodation is based on the ground floor. Communal space is provided throughout the building and there is a large well maintained garden. There are also laundry and kitchen facilities based on the ground floor. On admission to the home, people are not expected to stop drinking alcohol, however, they are offered support to reduce or stop their alcohol use. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16th December 2005 and was the second unannounced inspection. During the inspection time was spent talking with staff on duty and the registered manager. In addition people’s files, records and other relevant documentation were examined. As this inspection only looked at the standards that were not assessed at the previous inspection the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. The Commission for Social Care Inspection (CSCI) had not received any complaints about the home since the last inspection. What the service does well:
The home recognised the importance of providing people with a healthy and well balanced diet. This aim had been identified as an important goal in the home’s annual improvement plan. It was recognised that for people coping with alcohol use and those reducing their alcohol consumption, diet is an important part of their recovery and also the role of taking meals together provides both social and peer group support. The home has been operating a healthy eating programme over the past year trying to reduce the levels of salt and fat in people’s diet and offering them a range of fresh and nutritionally positive foods. Peoples’ health and the role of diet was also recognised by the home and an example was seen where they had worked with health specialists to develop an individual menu for one person. The home aims to provide a quality service to the people it supports. To try to find out whether they are doing this the home have put in place a number of activities to gain people’s views. All the people at the home can take part in regular ‘Residents’ meeting where they discuss what is important to them in the day-to-day life of the home. In addition, every month a member of the home’s management committee visits and asks people about the quality of the service. From the information gathered from people, staff and other relevant professions the home develops an annual plan for improving certain parts of the service. This year the home wants to involve people in developing a more healthy set of menus, improve supervision support to staff, ensure care plans are reviewed, improve the pre-admission information, involve people more in
Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 6 the decoration and furnishing of the home, provide support to help people achieve what they want to do and to improve the therapeutic activities people take part in at the home. This shows that the home is taking the issue of improving the quality of the service seriously and is devoting time and resources to involve people in finding out whether they are succeeding. Over the course of previous inspections the home has consistently shown that they are committed to providing staff with the training and learning required to support vulnerable people. In addition, the home has made a conscious effort to involve staff in sharing the role and responsibility of working with people to identify and review their support needs and the goals people wan to achieve. What has improved since the last inspection? 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 & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 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 & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 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): EVIDENCE: These standards were assessed during the previous inspection. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed during the previous inspection. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 10 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): 17 People were offered a balanced choice of meals that they generally enjoyed. EVIDENCE: The home offers people a choice of meals that are balanced and a menu based on people’s preferences. A range of alternative choices is offered to people who may not like the main meal. All meals are taken in the large and well presented dining room. People’s dietary needs had been assessed and were identified through the individual Care Plans. This assessment and support had included the input from community dieticians and other healthcare providers. People are consulted over their likes and dislikes and their nutritional needs are identified such as diabetes and other health related issues. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: These standards were assessed during the previous inspection. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 12 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 and 23 The home has the systems and practices in place to allow people to express their concerns and respond to protect people from abuse. EVIDENCE: The complaints procedure was clear and made available to all people both on arrival and was also discussed during residents meetings. It included information about the role of the CSCI in making complaints. A record was maintained of all the concerns and complaints people raised with the home. The home had an Adult Protection policy and procedure that met the requirements of ‘No Secrets’. A ‘Whistleblowing’ policy was in place as a response to the Public Disclosure Act 1998. The Protection of Vulnerable Adults (POVA) reporting procedures had been incorporated into the home’s recruitment and grievance policies. Staff had received ongoing training in adult protection, challenging behaviour and de-escalation techniques. The home has a Personal Finance Policy and procedure and evidence of written agreement’s that personal monies would be kept by the service and agreements that funds would be paid into individual saving accounts. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: These standards were assess during the previous inspection. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 14 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): 34 and 35 The home has the systems and policies in place to recruit staff that are safe to work with vulnerable people. Staff have access to the training and learning they require to support people’s needs. EVIDENCE: Staff files seen contained the relevant documentation as required under Schedule 2 of the Care Home Regulations. Staff files contained copies of or the original CRB certificate. It was also seen that POVA first checks had been made to allow staff to start work under the supervision of an experienced member of the staff team. Staff did not work unsupervised until the full CRB certificate was issued. It was noted that on one certificate the employer recorded was not the name of the home. The home’s CRB applications are countersigned by another organisation. It is recommended that the home check with the organisation to ensure that the correct procedure is being followed. It was also noted that the home did not have a system for checking when a CRB required renewing nor an annual check to ensure that staff did not have any criminal convictions. It is recommended that a system be developed that triggers the requirement to renew a CRB within the timescales set by the CRB. It is also recommended that the home put in place a system whereby staff are required to sign a statement that they have no criminal convictions on a yearly basis. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 15 Each member of the staff team has his or her own individual training and development plan and training log. This includes a comprehensive induction programme of core training and learning. When the staff member has been assessed as competent in each area a member of the management team will sign the plan. In addition to the induction training the home provides staff access to a range of training that relates clearly to their role and the skills required to support people needs. Training needs are discussed and identified with staff members during the supervision and annual appraisal process. This information then goes onto the individual training plan. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 16 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): 39 and 42 The home has the systems and practices to monitor and develop the service based on people’s views. However, some poor working practices do not protect the health and safety of people. EVIDENCE: Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 17 The home had developed a Quality Improvement Plan for April 2005 to March 2006. This set out key areas that the home aimed to make key improvements, the way these were to be achieved and how they were going to be measured and monitored which include the use of meetings and questionnaires. Members of the Mary and Joseph Management Committee took turns to carryout the monthly inspections of the service, as required under Regulation 26 of the Care Home Regulations. The premises were inspected and service users views gathered as to the quality of the service. Issues of the quality of the service were also discussed during the regular ‘Resident Meetings’. Any issues raised during these meetings were also presented to the Management Committee. The fire log showed that the required checks were being made. Documentation showed that fire, gas and electrical equipment was being serviced on a regular basis. A fire risk assessment had been completed but there was no evidence that it had been reviewed within the timescales set in the assessment. It is recommended that fire risk assessment include the hazards and risks of fire within people’s bedrooms especially in relation to smoking and the influence of alcohol. The home has health and safety policies and procedures and provides staff with relevant training. It was found that the system for monitoring and recording the temperatures of the kitchen’s fridges and freezers was not being adhered to accurately. The system used for monitoring and recording fridge and freezer temperatures must be accurate and staff must follow the procedure accurately. Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mary & Joseph Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000021619.V273807.R01.S.doc Version 5.0 Page 19 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 YA42 Regulation 13 Requirement The system used for monitoring and recording fridge and freezer temperatures must be accurate and staff must follow the procedure accurately. The fire risk assessment must be reviewed on an annual basis. Timescale for action 01/03/06 2 YA42 23 01/02/06 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 YA34 Good Practice Recommendations It is recommended that a system be developed that triggers the requirement to renew a CRB within the timescales set by the CRB. It is also recommended that the home put in place a system whereby staff are required to sign a statement that they have no criminal convictions on a yearly basis. It is recommended that fire risk assessment include the hazards and risks of fire within people’s bedrooms especially in relation to smoking and the influence of alcohol. 2 YA42 Mary & Joseph DS0000021619.V273807.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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