CARE HOME ADULTS 18-65
Mary & Joseph House Palmerston Street Ancoats Manchester M12 6PT Lead Inspector
Steve O`Connor Key Unannounced Inspection 17 and 23 November 2006 1:00 Mary & Joseph DS0000021619.V304542.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 & Joseph DS0000021619.V304542.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 & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Mary & Joseph House 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.V304542.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 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 16th December 2005 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. The current fees for the home are £425 per week. Information about the home can be provided by contacting the home direct. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the end of the last inspection in December 2005. This information includes a pre-inspection questionnaire, surveys of the views of people who live at the home, an action plan submitted in response to the last inspection report and an unannounced site visit to the home on the 17 and 23 November 2006. During the site visit time was spent talking to people who live at the home, the management team and several staff members. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. The previous inspection report had highlighted two areas that the home needed to improve. These had been fully actioned and met the NMS. No complaints or concerns were received by the CSCI in relation to the home. What the service does well:
The home continues to support men who, due to their alcohol use and/or other needs, require 24 hour supported accommodation. They have experienced a range of alcohol related problems that have seriously affected their general and emotional health, family and personal relationships, employment and finances. The home offers men the opportunity to be able to continue drinking alcohol if they wish, but in a safe environment. No restrictions are placed on alcohol or tobacco use unless agreed between the person and the home. Almost all the men have worked closely with the home to agree to manage their alcohol use in a different way. The home recognises the importance of the standard of people’s environment and in providing a comfortable, well-maintained and clean place to live. There is a range of communal rooms and activity areas that are all clean, well maintained and decorated. The garden and external grounds provide a colourful and peaceful area for the men to relax or to become involved in its design and upkeep. The corridors and communal areas are decorated with examples of peoples’ artwork and paintings.
Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 6 The home places a lot of importance and resources on being able to offer people a choice of opportunities and activities and letting them decide what they would like to take part in. The home has a dedicated art workshop where people can work on individual and group projects such as glass painting and mosaic work. There is a gardening group responsible for designing and maintaining the garden. The home recognises the importance of supporting people to improve their fitness and so provides mini-gym facilities and classes, support to go swimming and cycling and a football team that plays in a local league. People also want the chance to enjoy themselves and the home again place a lot of importance in offering a menu of social and leisure activities. These include a games room with a pool table and a weekly competition, films nights, bingo, day trips, meals out and all the people at the home are offered a week’s holiday. The home also supports people on an individual basis to take up opportunities for social, leisure and educational activities. The home was commended for the positive action and opportunities they offer to people who could then make the decision as to whether they wanted to take up any of these activities. One of the people spoken to during the visit to the home said to the inspector that they feel they have more control and choices over their own life and are involved in the way the home supports him and the other people. This can be seen through the work the home does with people to help them to manage their alcohol use. People are offered the opportunity to be as involved as they want in developing their own care plan, attending reviews and residents meeting, taking part in the activities and the therapeutic work offered by the home. An example of how the home are emphasising the importance of individual choice was seen in the way that holidays are being offered to people. Previously, the majority of people were offered the chance to go on an organised holiday to North Wales. For next summer the home is asking people what they want to do and where to go. The options will then be presented to the whole group for them to decide and make a choice. The home continues to recognise the importance of providing people with a healthy and well balanced diet. 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. As one person commented, ‘ meal times are very important and so the food needs to be good’. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 7 The home operates a healthy eating programme trying to reduce the levels of salt and fat in people’s diet and offering them a range of fresh and nutritional foods. People spoken to were very complimentary about the quality, choice and amount of food offered. They were encouraged to talk to the catering staff about their own personal diet needs and to provide feedback and suggestions. 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 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, people are asked to take part in filling in questionnaires that look at different aspects of the service. Every month a member of the home’s management committee visits and asks people about the quality of the service. Since the last inspection the home has further improved and developed the way they are trying to find out about the standard and quality of the services they provide. A Quality Assurance Team has been formed and consists of people who live at the home, members of the management team and staff. The purpose of the team is to look at all areas of the service the home provides and to look at how well the home is doing and whether it can improve. 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. This is seen as an example of good practice and is commended. 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. Staff spoken to during the visit to the home had a very good understanding of the people they worked with. They were aware of the issues and problems they faced but focused on the positives they found in people and concentrated on what people can do. They showed the skills and values needed to support a very vulnerable group of people. To be able to offer the support and help that a person needs and wants the home has to be able to understand the person, their background, the events that have affected their lives, their general and mental health and, most importantly, what the person wants to do and how they want to be supported. To do this the home has continued to work with people and find out what support they need. This looks at all areas of their life and encourages people to work with a named keyworker to develop a Care Plan. This Care Plan sets out in a clear and detailed way what a person needs and what they would like to
Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 8 achieve in their lives. It gives lots of information about the things that are important to that person and describes how the home is going to support them. This means that not only are staff clear about how they should be working with people but it also gives the men greater control over their life at the home and not have things just done for them. Since the last inspection report the home has progressed even more in the way that they work with people in finding out what is important for the person and not convenient for the staff team or service. This person centred thinking and planning can be seen in the way that the care plan focuses on the positive aspects of people’s lives and how they can make the changes they want. For example, the home has put in place a daily living skills programme for people who want to maintain and/or gain more independence. The home have put a lot of thought and hard work into developing this person centred care planning system and providing staff with the encouragement, guidance and training needed to make it work. This was highly commended. 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.V304542.R01.S.doc Version 5.2 Page 9 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.V304542.R01.S.doc Version 5.2 Page 10 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were fully assessed prior to admission to the home. EVIDENCE: The home had a clear and structured referral process for people who may want to come and live at the home. The purchasing authority provided either a Nursing assessment, Care Management (CM) or Care Programme Approach (CPA) assessment. The home also undertook their own initial pre-admission assessment that usually involves visiting the person and meeting any relevant people such as family or other professionals. From this information the home decides whether it can meet a persons’ needs. The person is also invited to visit the home and spent time with other residence and staff and talk about the service. In addition, people were provided with an information pack that contains the home’s Statement of Purpose and a Service User’s Guide to help them make an informed choice regarding the decision to come to live at the home. During the first six weeks of a person’s stay the home will carry out ongoing assessments and work with people to find out what their needs are and whether the home is the right place for them to live. Mary & Joseph DS0000021619.V304542.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home had the policies, procedures and systems in place to identify people’s ongoing goals and needs and allows them to make decisions and choices and to take risks within a supportive environment. EVIDENCE: The purchasing authority will normally provide the home with a purchaser care plan prior to a person coming to live at the home. These can vary in detail and complexity. The home had continued to implement a care planning process that allowed for an in-depth description of people’s individual needs and made clear reference to the agreed goals and the support required to meet those goals. The responsibility for developing the Care Plan was with the person and their key worker that allowed the development of a relationship and also focused on what the person wanted to achieve. Ongoing training had been provided to help the staff to develop their assessment and care planning skills. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 12 The care plan review process provided a detailed record of people’s goals, the support offered to meet those goals and a summary of the effectiveness of the support. Changes to the care plan were discussed with the person during the review had been clearly recorded. The care plan reviews recorded people’s views on the progress they felt they were making. Since the last inspection the home has further developed the way they work with people through the use of person centred planning. This focuses on what the person feels is important for them and what they want to achieve. It is recommended that the home makes sure that care plans are updated on a regular and ongoing basis. The use of person centred planning in the care planning and review process continues to be an area of good practice and was commended. The Risk Assessment and Management Policy contain a clear procedure for undertaking risk assessments. Issues of risk, especially in relation to peoples’ alcohol use, mental health and general health, were identified during the preadmission process and on an ongoing basis through the care plan review process. Evidence was seen that people were as fully involved as possible in the risk assessment process and reviews. A number of relevant risk assessments were seen covering environmental, behavioural and personal care issues. The assessments were thorough and gave clear details of how to support people to manage risks. As people were as fully involved as they want/can in the care plan and risk assessment process they were able to make the choices and decisions on what areas of their life they want to change or maintain. People were supported on an individual and group level to become involved in the running of the home and the services and activities provided. This included regular meetings involving people and the staff team and involvement in the homes quality assurance planning and development. Restrictions of choice were made only as a result of a risk assessment, involvement of the person and a written agreement. The home had sought information and contacts regarding advocacy services and has provided people with this information. Mary & Joseph DS0000021619.V304542.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home providee the opportunities and support to allow people to chose to participate in a range of valued social, leisure, and therapeutic and educational activities. People were offered a balanced choice of meals that they enjoyed. EVIDENCE: As the homes’ care planning process focuses on what the person feels is important and what they want to achieve the provision of meaningful and valued activities is a very high priority for the home and they allocate a lot of their resources on meeting this area of need in peoples’ lives. The home provided a personal tailored programme of therapeutic and social events that people can participate in, if they wish. This included art groups, fitness, gardening and a life skills programme. The home also supported people to take part in social and leisure activities in the community both on a one-to-one and group basis.
Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 14 Peoples’ routines and activities were based on their own support plan and personal choices and decisions. Families and friends were encouraged to remain an important part of peoples’ lives and can visit at any reasonable time. The home continued to offer people a choice of meals that were balanced and a menu based on people’s preferences. A range of alternative choices was offered to people who may not like the main meal. All meals were taken in the large and well-presented dining room. People expressed their satisfaction with the standard and choice of meals. 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 were consulted over their likes and dislikes and their nutritional needs were identified such as diabetes and other health related issues. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided the support and access to health services to maintain people’s person and healthcare. The medication administration was generally safe but did require a formal auditing process to ensure that people had received all the required medication. EVIDENCE: The home continued to maintain people’s personal care needs and goals and the support was clearly recorded in the Care Plans. Moving and Handling risk assessments had been completed for people who required hands-on support. Equipment and aids such as grab rails, a shower chair and hoist were available to support personal care needs and specialist input from health providers such as occupational therapists and physiotherapists was used in providing guidance and advice on equipment and support needs. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 16 Care plans contained detailed medical histories and of health needs gathered from current and previous health service input. People were supported to attend and access regular appointments with G.P’s, chiropodists, dentists, district nurses and community psychiatric nurses. The home worked closely with the community alcohol and mental health teams. The medication administration system was checked and found that all recording of administering on the Medication Administration Records (MAR) was accurate. Deliveries of medication are checked and should be recorded on the MAR sheets. However, it was found that for the last delivery there was no record on the MAR sheet. Returns are recorded and signed by the pharmacy. The stocks of medication were checked but there was no formal record that a medication audit had been undertaken to show that people had received all the required medication. The home must undertake a regular formal audit of medication. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had 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 home meetings. The Complaint Policy and procedure was clear and detailed with set timescales for the home to act and respond. A record of all complaints was kept and these included details of the complaint, the actions taken and the outcome of the complaint. The home’s Management Committee will monitor and review all complaints on a regular basis. 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 were incorporated into the home’s recruitment and grievance policies. The home operated an incident recording system where all incidents that affect the welfare of people and staff are recorded and linked to the review of peoples’ risk assessments and support guidance. Staff had received ongoing training in adult protection, challenging behaviour and de-escalation techniques. The training staff received also included the use
Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 18 of ‘breakaway techniques’. It was found that the home did not have a clear Physical Intervention Policy and procedure. The home had 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. A member of the management team acts as an appointee for several people. Peoples’ ability to manage their own finances was established through the assessment process and in consultation with the relevant purchasing authority. The home brings in an external accountant to undertake a yearly audit of all the internal finances and those of people living at the home. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a pleasant, well-maintained and safe environment. EVIDENCE: The home provides 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 was a large well-maintained garden. There was also a laundry, kitchen facilities, a medical room and a chapel based on the ground floor. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 20 The home was clean, well maintained and the communal rooms were comfortable and well laid out for people to use. There was an ongoing programme of decoration and improvement throughout the home and people were involved and consulted in decisions and choices. The communal areas were decorated using artwork that people made themselves through the art group. The home had a dedicated domestic team who maintain a high level of cleanliness and hygiene throughout. The laundry facilities were sufficient to meet peoples’ needs and infection control measures, procedures and equipment is in place to minimise cross infection. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People were being supported by a knowledgeable and committed staff team in all areas of their life at the home. There was a high ratio of support and ancillary staff to meet peoples’ support needs. The home’s recruitment policies, procedures and practices ensure that staff have undertaken the required checks so that they can work with vulnerable people. The home was committed to developing staff vocational and training programmes to ensure the staff have the skills they need to support people to a high standard. EVIDENCE: The home had a staff team that consisted of the Manager, Deputy Manager, four senior support workers and 18 support workers. The team also had a Head House Keeper, Catering Manager, Administrator and around 14 domestic and catering staff. In addition the home also employed three specialist therapeutic staff working on specific projects and work groups. The daily staffing levels were flexible and can change depending on individual and the group needs and in response to organised events and activities. Staff turnover and sickness levels were low for the care sector. Regular staff meetings were held to provide a forum for management and staff to raise issues and maintain effective communication
Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 22 Time was spent talking to three of the staff and observing several other staff on duty at the time of the site visit. All those spoken to show a very good understanding of the people they support, of the problems they face and the support they required. People were spoken about in a very positive way and did not focus on negatives or problems. They were aware of their role and responsibilities in terms of their key worker role and in supporting people to meet their goals. The staff were able to discuss the training they had undertaken and the skills developed through the training plan and through support from the management team. People spoken to during the site visit expressed very positive views on the whole staff team from the management, support workers, domiciliary and catering staff. The interaction seen between people and staff was seen to be very friendly and respectful. The home had a commitment to providing its staff team with a vocational training programme. Of the support workers over 70 have gained the NVQ Level 2 and many have and are undertaking the Level 3 and above. 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. Each member of the staff team had his or her own individual training and development plan and training log. This included a comprehensive induction programme of core training and learning. When the staff member had been assessed as competent in each area a member of the management team would sign the plan. In addition to the induction training the home provided staff access to a range of training that related clearly to their role and the skills required to support people needs. Staff training needs were discussed and identified during the supervision and annual appraisal process. This information then goes onto the individual and team training plan. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People benefit from having a skilled and experienced management team. They were actively encouraged and supported to be involved in looking at the quality and development of the service and the home’s systems for health and safety keep people safe. EVIDENCE: The home had a clear management structure and lines of responsibility and accountability. The home was currently in the process of applying for a new registered manager who is currently the deputy manager. Both the Registered Manager and deputy manager are experienced and suitably qualified to run the home. The management style of the home is open and accessible for the people living at the home and the staff team. Comments from people spoken to was very positive about the way the management team listen to them and are easy to approach and talk to about any problems and Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 24 concerns they have. Staff also commented that they felt valued and supported by the management team. Over the past 12 months the home had further developed and improved its quality assurance programme. Members of the Mary and Joseph Management Committee still 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. A Quality Assurance Team has been set up that includes people voted for by all the other people living at the home and management and staff from different departments. The purpose of the team was to coordinate and bring together information gathered about the quality of the home and to develop actions to further develop and improve the service people receive. The home chose an aspect of the service that they want to find out about. Peoples’ views were sought through the use of questionnaires and residents meetings about these areas and parts of the service. Examples were seen where issues such as choice and control, daily living experience, discrimination and dignity and respect were looked at using the quality assurance system. The commitment shown by the home to take the issue of peoples’ involvement in shaping the direction of the services provided is seen as an example of good practice and is commended. The previous inspection report highlighted two areas of health and safety that needed slight improvements. The temperature of the fridges and freezers in the kitchen were now being correctly monitored and recorded and the home’s fire risk assessment had been reviewed. 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. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 4 X X 3 X Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement The home must undertake a regular formal audit of medication to ensure the safe administration of medication. The home must develop and implement a Physical Intervention Policy and Procedure to provide the correct guidance for staff. Timescale for action 01/01/07 2 YA23 13 (6) 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the home makes sure that care plans are updated on a regular and ongoing basis. Mary & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 27 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
© 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 & Joseph DS0000021619.V304542.R01.S.doc Version 5.2 Page 28 - 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!
