Inspection on 28/04/05 for Mary`s Home

This inspection was carried out on 28th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mary`s Home 12/08/08

Mary`s Home 12/06/07

Mary`s Home 03/05/06

Mary`s Home 09/12/05

Mary`s Home 29/10/04

Mary`s Home 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Marys Home 88 Warham Road South Croydon Surrey CR2 6LB Lead Inspector Lee Willis Announced 28 April 2005 9:30 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 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 Older People. 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. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Marys Home Address 88 Warham Road, South Croydon, Surrey, CR2 6LB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8688 2072 020 8667 9242 Dr Edward N Osei Appah Care Home 29 Category(ies) of Mental Disorder - over 65 (29) registration, with number of places Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A variation has been granted to allow six specified service users under the age of 65 to be accommodated. Date of last inspection 29th October 2004 Brief Description of the Service: Mary’s Home is registered with the Commission for Social Care and Inspection (CSCI) to provide residential accommadation and personal care for up to twenty-nine generally older adults, i.e. 65 and over, with a past or present experience of mental ill health. The youngest service users currently residing at the home are in their fifties and the Commission is in the process of amending the homes conditions of registration to ensure this situation is accurately reflected on its Certificate of Registration. Regina North continues to be the homes acting manager where she has been in operational day-to-day control for almost two years. Dr Edward Appah and Mrs Helen Appah remain the registered co-owners of the home. Since the previous inspection the number of places the home offers has more than doubled from thirteen to twenty-nine. This was achieved by integrating the neighbouring house (No#90) with the existing home. The home now comprises of twenty-three single occupany bedrooms, sixteen of which have their own ensuite facilities, and three doubles. The layout of the homes existing communal space has also been altered and now includes a seperate dinning room and new lounge. The kitchen has also been refitted and two new bathrooms, a laundry, sluice room, two offices, and a passenger lift have also been installed in the new wing. The former office has been converted into a staff room. Work on the conservatory is now complete. The garden has a new patio area and the lawn has been re-laid. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 9.30am. It took place over five and a half hours during the morning and early afternoon of Thursday 28/04/05. People living at the home had all been made aware that an inspection was due and eight service users spoken to at the time were all willing to share their views about life at the home. A visiting guest of one of the service users was also spoken to. A total of sixteen completed comment cards were returned to the Commission from service users and their relatives. The comments made were generally favourable about the standard of care being provided, although some concerns were raised about the lack of outings and day trips being offered to service users. The homes owner, acting and deputy managers, and several members of staff on duty at the time were also interviewed at various times throughout the course of this inspection. The duration of the inspection was spent examining records, touring the building, and as mentioned above, speaking to almost a third of the service users, one of their guests, the proprietor, the homes managers, and care staff on duty. There have been no additional or complaints visits carried out on the service in the past inspection year (April’04 to April’05), although the homes co-owners and acting manager were all invited to attend a meeting at the Croydon offices of the CSCI in March’05 and provide an action plan setting out how they intended to address poor practice issues identified at the homes last three inspections. Comments are made in the main body of this report on the progress made by the home to resolve many of these on going matters. What the service does well: The feedback received from service users met during the inspection and from comments cards was on the whole very positive. Two service users who had only recently moved into the home and occupied bedrooms in the new extension were particularly impressed with the their ensuite facilities and the way staff respected their privacy. Several service users met said what they particularly liked about living at Mary’s home was the fact that staff never ‘hassled’ them into joining in activities they didn’t want to do and that they could spent as much time in their own company as they wished. The vast majority of the service users spoken to during the inspection were very clear who they would talk to if they had a problem or were worried about something. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The positive comments made overleaf notwithstanding, there are still some areas of the service that need to be improved. There are seven areas of major concern that need to be addressed. Firstly, further amendments still need to be made to the homes Statement of purpose to ensure it includes all the information service users and their representatives need to know about the homes operation. Care plans and risk assessments must set out in greater detail what action must be taken by staff to meet service users identified needs. More outings and day trips must be organised. All complaints received by the home must be logged and include details about all the action taken (if any) to resolve the matter. Staff need to receive training in a number of core areas, including fire safety, working with people with a past or present mental illness, and recognising, preventing and reporting abuse. The number of formal supervisions each member of staff receives each year must be increased. Finally, all new members of staff must be checked against the recently established Protection of Vulnerable Adults (POVA) register before being allowed to start working at the home. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 & 6 The service users guide has significantly improved since the last inspection and now contains more detailed information about the home to enable any prospective service users and their representatives to make informed decisions about whether or not to move in. Further revision of the homes Statement of purpose is still needed to ensure service users and their representatives have all the information they need to know about the homes operation. Written, signed and costed contracts are provided, ensuring the service users are not only aware, but also agree, with the terms and conditions of their occupancy. The home has a preadmissions assessment tool which is in the main sufficiently detailed to ensure no service users move into the home without their needs being identified, although some amendments are still needed to ensure every aspect of a prospective service users personal, social and health care needs are covered. Without this information staff will be unable to plan for and meet the needs of new residents. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 10 EVIDENCE: As required in the homes previous report the service users guide has been sufficiently amended to include all the information specified in the National Minimum Standards and associated Regulations (2001). Three service users spoken with said they had been give a copy of the recently revised guide, which they keep in their bedrooms. The home’s Statement of purpose has also been amended although further revision is still needed. Previous inspections have highlighted the need for the homes Statement of purpose to contain more specific information about the age range and needs of the people for who the service is intended; the number and relevant qualifications of the staff team; the organisational structure of the home; more specific details about what opportunities service users have to pursue their social and leisure interests; what arrangements are in place to consult the service users about the homes day-to-day operation; and what arrangements are in place to deal with fire and other emergencies. Individual records are kept for each of the service users and having sampled three at random the documents revealed that service users are provided with written and costed contracts that set out their terms and conditions of occupancy, which the manager and each service user or their representatives sign as proof of agreement. One service user who had only lived at the home for the past two months said he had been given contract, which he had not yet signed, because he was in the process of negotiating new terms and conditions of occupancy with the owners. Contracts viewed contained all the relevant information required by the Standards, including fees charged, what they covered, the cost of ‘extras’, and periods of notice to be given in the event of a placement being terminated. There have been twelve new admissions since the last inspection and the tool the home uses to assess the needs of prospective service users is adequate. Staff then use this information to generate care plans to meet identified needs. Having examined assessments undertaken by the manager in respect of three of the homes most recent admissions it was evident that the tool needed to be improved to include more detailed information about service users basic foot care needs, history of falls (if any), family involvement and other social contacts, and service users wishes concerning terminal illness and death. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 With the introduction of a new care plan format some progress has been made on improving information held by the home about each service users personal, social and health care needs and preferences. However, the new format is not sufficiently detailed to ensure staff know what action to take to meet these needs and minimise risk, particularly risks associated with daily living and health care. This lack of detailed guidance for staff has the potential to place the service users at risk of harm. Based on individual assessments of risk service users who are willing should have the opportunity to be responsible for administering their own medication, thus ensuring their rights to exercise choice is not restricted unnecessarily and, so far as reasonably practicable, their independence maximised. In general service users feel the staff respect their privacy and dignity, although staff sometimes need to be reminded to always knock on bedrooms doors before entering. A template to record service users wishes concerning dying and death is now available in the home. These documents must be completed to enable staff to handle the death of a service user, as the individual would wish. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 12 EVIDENCE: Individual plans of care are available for each of the service users and although they remain basic significant progress has been made since the homes last inspection to ensure that all aspects of service users personal, social and health care needs are assessed and planned for. Three new care plan formats were sampled at random and revealed that more detailed information about each of the service users food preferences and social interests was being recorded and planned for. Three service users spoken to described their social and leisure interests, which corresponded with the information contained in their new care plans. However, the new care plan format did not contain very much specific information about what action was to be taken by staff to meet each of the service users identified needs and what their goals were. Discussions with the manager and staff suggest that most needs were being addressed even though there was a lack of clear guidance for them to follow in the care plans. Similarly, although some risk assessments are in place more will need to be undertaken to ensure ever aspect of service users life’s, particular those concerning health care are covered, including the actions to be taken to minimise risks associated with epilepsy, diabetes, falls and incontinence. Several service users spoken to were all able to describe some of their health care needs, and although these were recorded in their care plans, no documentary evidence was available to show what arrangements the home had put in place to minimise these identified risks. Discussions with the homes senior management team suggested that care plans are being reviewed on a monthly basis and up dated accordingly to reflect changing needs, although there was no documentary evidence to show that this task was being undertaken. This rather informal approach is dependent on staff memory and good communication and may break down. As with annual reviews of care plans appropriate records must be maintained. Two service users spoken with said they were always invited to attend their annual care plan review and agree any changes. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 13 Service users met all confirmed that staff continue to support them keep in regular contact with their General Practitioners and other community based health care professionals, including psychiatric nurses and NHS chiropodists. Individual case files record contact with health care professionals and the outcome of these appointments. The homes records revealed that no service users have been admitted to hospital in the past six months and that the three accidents that have involved service users all pertain to falls (See Requirement No# 4). As previously mentioned, although care plans contain information about service users emotional and psychological health more specific details about how the home intends to support them meet these needs must be recorded (See Requirements No#3). The staff use a well known monitored dosage system to manage medicines in the home. No recording errors were noted on medication administration sheets sampled at random. None of the twenty-seven service users currently residing at the home are responsible for managing their own medication. Based on individual assessments of risk service users who are able to perform this task should be given the opportunity to self-administer their medication if they choose to. Two service users spoken with said they have keys to lock their bedroom doors and that it is customary for staff to knock on their bedroom doors to ask their permission to enter before doing so, although this practice has a tendency to lapse from time to time. This matter was discussed with the manager and it was agreed it would be raised with the staff at the next team meeting. Some progress has been made in establishing a template to record service users wishes regarding terminal illness and death, although the majority remain incomplete. Service users and their representatives should be involved in planning for and dealing with growing older and arrangements to be put in place in the event of death. The outcome of these discussions must recorded, and it is recommended this is done at the admissions stage (See Requirement No#1). Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Some progress has been made on improving arrangements to identify service users social, leisure and recreational interests are provide them with far greater opportunities to take part in ‘age’ appropriate activities within the home, although more work is needed to ensure service users and their representatives expectations and preferences regarding community based activities, especially day trips and outings, are realised. In the main service users are actively encouraged and supported by staff to exercise choice and control over their lives, although more could be done to improve the homes current arrangements by offering front door keys to those service users who are willing and able to use them. Meals appear to be nutritionally well balanced, nicely presented, and provide daily variation and interest for the people living in the home. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 15 EVIDENCE: An activity programme is available for those service users who choose to take part and on the day of the inspection an activities co-ordinator, who is employed by the home to organise music and movement classes, was observed encouraging the service users to join in a gentle exercise class. Several service users met during the course of the day said the activities cocoordinators visit the home twice a week and religious services continue to be held every morning for those who choose to participate. Information about the homes activity programme is conspicuously displayed on the notice board. One comment card returned to the Commission from a relative of a service user believed the residents did not go on enough day trips and outings as stated on the notice board. This matter was discussed with the homes deputy manager who acknowledged this was an area where the home could do better and was already in the process of consulting the service users about places to they could visit this Summer. The home does not have its own transport, but the deputy manager said a bus has been hired in the past for day trips. Recently amended copies of the homes visitor’s policy were available on request. The one service user met said he was not aware of any restrictions on ‘reasonable’ visiting times. Information about how service users and their relatives can contact external advocates is contained in the homes guide. All the service users spoken to said they are offered keys to their bedrooms, but not the front door. Several care plans sampled at random indicate that some service users access the wider community without the need for staff support. Based on individual assessments of risk service users who are able to use a front door key should be given a set if they choose to have one. Service users met during lunch said their meals were delicious and that they always had a choice. The displayed menu choices for the day matched the meals served on the day. The two choices of lamb or pork served with potatoes and assorted roast vegetables appeared to be nutritionally well balanced, hot and nicely presented. All the meals came ready served with gravy and it is recommended that in future arrangements are put in place to ensure service users can decide for themselves what sauces to have with their meals (if any). It was noted that salt and pepper condiments were available on each of the dining room tables and the recommendation is made that sauceboats are also provided. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 & 18 On the whole residents are confident that their concerns will be listened to, taken seriously and acted upon in accordance with the homes written procedures. An accurate record of all the complaints the home receives, including details of the subsequent investigation and actions taken in response must be appropriately maintained as proof of compliance with the outcome of standard No#16. The homes policy on dealing with aggression must be amended and the word restraint removed from the text as it not only contravenes the homes underpinning philosophy, but also places the service users at risk of being abused by staff who have not been suitably trained in the use of physical intervention techniques. Similarly, service users care plans must include more specific guidance to enable staff to support service users assessed as likely to be aggressive and protect them from being abused. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 17 EVIDENCE: Several service users spoken to about the attitude of staff said that staff were generally very approachable and willing to listen to any concerns they may have. In the past year the Commission has received one complaint alleging poor practice in the home. Following an investigation, the vast majority of the complaint was not upheld, although the homes recording of complaints was found to be inadequate. At this visit the complaints record held in the home shows no complains have been received since the previous inspection in October 2004, but comments made by the manager and one service user in particular, revealed that several had been brought to the attention of the home in the past two months. The manager and the individual who made these complaints told the inspector at a three-way meeting held in the home at the time of this visit that all the concerns raised had now been investigated by the home and successfully resolved to the complainants satisfaction. The manager is reminded that all the complaints they receive about the homes operation must be recorded, including any action taken in response. The home has a detailed complaints procedure, which contains all the information required by the National Minimum Standards and the associated Regulations (2001). One service user suggests that he has never been given a copy of the procedure despite numerous requests to be given one. It was agreed at the time of this visit that he should be given a new copy. It was noted that a summary of the complaints procedure is included in the service users guide. A procedure for responding to allegations or suspicion of abuse was available for inspection on request, along with a policy for dealing with aggression. This policy makes reference to restraining service users, which must be removed from the text as a matter of urgency, as this practice would only contravene the homes philosophy of care of not using physical intervention techniques to deal with aggression, but none of the staff have been suitably trained to use restraint as a ‘last resort’. The manager said arrangements were now in place for two-thirds of the current staff team to attend an accredited recognising, preventing and reporting abuse training course in June 2005. Records show that there have been no allegations of abuse or staff referred for possible inclusion on the Protection of Vulnerable Adults (POVA) register in the past twelve months. It was clear from care plans sampled at random that some individuals living at the home may challenge the service from time to time and be verbally and/or physically aggressive. Despite these needs being identified in individual care plans they were not always sufficiently detailed to equip staff to deal with aggressive and/or challenging behaviour. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24 & 26 Significant improvements to the physical environment of the home have been made to the property in the past twelve months to ensure the service users have access to a clean, safe and homely environment. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 19 EVIDENCE: Since the last inspection the service providers have completed all the building work on the new extension and structural changes to the existing home. Several service users and one of their guests who was visiting at the time said they “liked the recent structural changes to the home, particularly the new separate dinning and lounge areas”. One service user who had recently moved into one of the bedrooms in the new wing said he was “delighted” with the layout and décor of his new room and was particularly pleased with his ensuite facilities. The home now has sixteen bedrooms with ensuite facilities, two new bathrooms, separate lounge and dinning areas, a redecorated conservatory, a new laundry room, sluice, two offices, a passenger lift, and a staff room. It was positively noted that all the outstanding requirements from the homes three previous inspection reports pertaining to the physical environment have now all been met in full. A fire safety officer from the London Fire and Emergency Planning Authority and an Environmental Health officer have inspected the home in the past twelve months and no requirements were identified in the subsequent reports. Significant improvements have also been made to the garden, which has a new patio area for service users to sit and relax on and a newly laid lawn. As required in previous reports cords attached to call bells have now all been extended to ensure service users can still access the alarm from the floor should they fall. As part of a tour of the premises eight bedrooms on different floors of the existing building and new wing were viewed. All the bedrooms seen in the new wing were decorated to a ‘high’ standard, very personalised and contained all the furniture and fittings set out in Standard No#24. Two service users met while touring the new extension said they were delighted with their new rooms. All the bedroom doors, which are fire resistant, have been fitted with suitable locks that can be overridden by staff in case of an emergency. The homes new laundry room in the new wing has walls and floors which are readily cleanable and hand washing facilities available in an adjacent room. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Some progress has been made to ensure the staff are suitably qualified and competent to meet the emotional health care needs of the service users, although sufficient numbers of staff, including new recruits, still need to attend fire safety and mental health training to ensure they carry out their duties effectively and safely. The homes recruitment procedures need to be tightened up by ensuring protection of vulnerable adults checks are always obtained before any new members of staff are allowed to commence their employment. It is vital this is done to ensure that so far as reasonably practicable service users are not placed at unnecessary risk of harm or abuse from individuals who are not ‘fit’ to support them. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 21 EVIDENCE: The number of staff on duty at the time of this visit matched the duty rosters and revealed that the home continues to employ at least three carers throughout the day, excluding the managers who are supernumerary to this calculation. Managers take it in turns to be ‘on call’ at the weekends. A cook and a cleaner are always on duty in the mornings. At night staffing levels have increased to meet the needs of the services whose numbers have more than doubled in the past six months. Records indicate that the home has not used any agency staff in the past eight weeks. Documentary evidence was available on request to show that two members of staff have successfully completed a National Vocational Qualification in care. Two other members of staff are aiming to have achieved this award by the end of May 2005. The manager is aware that to ensure that 50 of the homes current staff team have achieved or at least started their NVQ level 2 training in care by the end 2005 three more members of staff need to enrol on the course. Since the last inspection the home has employed four new care workers and one cleaner. All five of the new recruits files were examined and although they contained the vast majority of information required by the Regulations (2001), including two written references, proof of identity and enhanced criminal records checks, three files did not contain any documentary evidence to show that they had been checked against the Protection of Vulnerable Adults register. Staff records sampled at random revealed that two members of the new intake of staff had both been given a structured induction, which was on going and had started on the first day of their employment. The staff team have attended a number of training courses that are relevant to the work they are expected to perform, including basic food hygiene, health and safety, and fire prevention. The manager acknowledges that insufficient numbers of the current staff team have received up to date training in fire safety and prevention and will need to attend suitable courses. The manager also produced a letter from Age Concern regarding dates in June for eight members of her staff team to attend a mental health in later life course. All the service users spoken to said the staff working at the home were in the main very kind and helpful. The manager and staff members on duty at the time of this visit were observed interacting with the service users in a very caring and respectful manner throughout the course of the day. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33, 36 & 38 The guidance the staff team receive from the manager ensures the service users are provided with consistent quality care. There are clear lines of accountability within the home and the management style is very open and transparent. The homes record keeping and written policies and procedures are in the main up to date and appropriately maintained to ensure the home is run to promote and protect the health, safety and welfare of the people who live there. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 23 EVIDENCE: The acting manager, Regina North, has been in operational day-to-day control of the home for nearly two years. She is still in the process of obtaining her registered managers award, which she hopes to have achieved by the end of June 2005. The acting manager has recently submitted an application for the Commission to consider registering her as the permanent manager, subject to a ‘fit’ person interview. Records indicate that staff meetings are carried out once every two months, the last of which was held in March 2005. The range of topics covered at this meeting included report writing, staff communication, medication and keyworking responsibilities. The home has a quality assurance system which is based on seeking the views of service users and their representatives through questionnaires. The results of these surveys have not been published by the home because the manager says that very few forms have been completed and returned to the home. The home needs to make more of a concerted effort to ascertain the views of service users by possibly helping the service users fill out the questionnaires. Staff files sampled at random revealed that most carers had only had the one formal supervision with a suitably qualified senior member in the past six months. This shortfall was identified in the homes last three inspection reports and the manager is reminded once again that all staff must receive at least six recorded supervisions a year on a Bi-monthly basis. The home is well maintained and suitable arrangements are in place to promote and protect the health and safety of the service users and staff. Inspection of the homes fire records indicated that the fire alarm system continues to be tested on a weekly basis and all staff participate in fire drills undertaken every quarter. Up to date Certificates of worthiness were in place for the homes electrical wiring, new passenger lift, fire extinguishes and portable electrical appliances. The manager said the homes gas (Landlords) installation check has been carried out by a suitably qualified professional in the past twelve months, but was unable to locate the documentation at the time of this visit. Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 1 3 3 2 x x 1 x 2 Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4(1)(c) (2), Sch 1(2,3,4,5, 6,9,10 & 11). Timescale for action The homes Statement of purpose 31/7/05 must contain more specific information about the age range and needs of the service users; staff numbers and qualifications; the homes organisational structure; arrangements made for service users to engage in social activities and participate in the day-to-day operation of the home; and arrrangements in place to deal with fire and other emergencies. A copy of the amended version must be supplied to the Commission and each of the service users. Previous timescale of 1st July 2004 not met. The homes pre-admission 31/7/05 assessment tool must be amended to include more specific information about new service users basic foot care needs; history of falls; family and social contacts, and wishes concerning death. Care plans must set out in 31/7/05 greater detail the action to be taken to meet every aspect of service users personal, social and health care needs. Version 1.30 Page 26 Requirement 2. 3 14(1) 3. 7 12(1), 15(1) & 17(1)(a), Sch 3.3(m) Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc 4. 7 12(1), 13(4) & 15(1) 5. 6. 7 9 15(2)(b) 12(1) & 13(2) (4) 7. 10 12(4)(a) 8. 16 17(2), Sch 4.11 & 22(3) 9. 16 22(5) 10. 18 15(1) & 17(1)(a), Sch 3.3(q) 13(6) & 18(1) 11. 18 12. 18 13(4) (6) A more comprehensive set of risk assessments must be undertaken by the home setting out the action that needs to be taken by staff to minimise identified risks, particularly those associated with health care, e.g. epilepsy, diabetes, falls, and incontinence. Previous timecale of 1st July 2004 not met. Care plans must be reviewed on a monthly basis, up dated accordingly and records kept. Based on individual assessments of risk service users who are willing and able must be gvien the opportunity to manage their own medication. Staff must be reminded to always knock on service users bedroom doors and ask the occupants permission before entering. Any complaint made under the homes complaints procedures must be investigated and a record kept of the outcome, including any action taken, if any, in response. Each service user who requests one must be provided with a written copy of the homes complaints procedure. Individual care plans must contain more specific guidance on how to deal with aggression. Previous timescale of 1st January 2005 not met. Sufiecnt numbers of the curetn staff team must attedn suitable training in recognising, preventing and reporting vulnerable adult abuse. Previous timescale of 1sts Febrauty 2005 not met. The homes policy on dealing with aggression must be amended and the word restraint removed 31/7/05 31/7/05 31/7/05 31/7/05 18/7/05 18/7/05 31/7/05 30/9/05 18/7/05 Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 27 from the text. 13. 29 13(6) & 19(1) All new members of staff must be checked against the new Protection of vulnerable adults register before being allowed to commence their employment. All staff working in the home must receive suitable training in fire safety and prevention. Sufficient numbers of staff must attend an age appropriate mental health training course. All staff working at the home must recieve at least one formal supervision with a suitably qualified senior every two months. Previous timescale of 15th May 2004 not met. Documentary evidence to show that the homes gas installations Landlords check has been tested by a ‘suitably’ qualified professional in the past twelve months must be forwarded to the Commission. 18/7/05 14. 15. 16. 30 30 36 18(1) & 23(4)(d) 18(1) 18(2) 31/7/05 31/8/05 131/8/05 and henceforth 17. 38 13(4) 31/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 11 15 Good Practice Recommendations The registered person should ensure service users have far greater opportunities to go on regular day trips and outings. The registered person should ensure suitable arrangements are in place to enable the service users to have a choice about whether or not to have gravy poured on their food at meal times. 50 of all the carers working at the home should have obtained, or at least started, an NVQ level 2 or above in care by the end of 2005. The manager should have achieved an NVQ level 4 in management and care by the end of 2005. G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 28 3. 4. 28 31 Marys Home Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 29 Commission for Social Care Inspection Croydon, Kingston & Sutton Office 8th Floor, Grosvenor House 125 High Street Croydon, CR0 9XP 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 Marys Home G53-G53 S25811 Marys Home V181383 280405 Stage 0.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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