Inspection on 03/05/06 for Mary`s Home

This inspection was carried out on 3rd May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mary`s Home 12/08/08

Mary`s Home 12/06/07

Mary`s Home 09/12/05

Mary`s Home 28/04/05

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 Mary`s Home 88 Warham Road South Croydon Surrey CR2 6LB Lead Inspector Lee Willis Key Unannounced Inspection 3rd May 2006 10:30 X10015.doc Version 1.40 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`s Home DS0000025811.V292421.R01.S.doc Version 5.1 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 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. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mary`s Home Address 88 Warham Road South Croydon Surrey CR2 6LB 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) 020 8688 2072 020 8667 9242 Dr Edward N Osei Appah Mrs Helen Appah Mrs Regina Anima North Care Home 29 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (29) of places Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow six specified service users under the age of 65 to be accommodated for as long as the home is able to meet the assessed needs of the service users. 9th December 2005 Date of last inspection Brief Description of the Service: Mary’s Home is a privately owned residential care home that provides accommodation and personal support for up to twenty-nine generally older adults with a past or present experience of mental ill health. Regina North, who became the homes registered manager in April 2005, has been in operational day-to-day control for nearly three years. Set back from a busy thoroughfare in South Croydon the home is within fifteen minutes walk of the centre of town with its wide variety of local shops, cafes, pubs, and banks. The home does not have its own transport, but it is situated on a main line bus route and is within ten minutes walk of a local train station, with good links to central Croydon, London, and the surrounding areas. Built over three storeys this recently extended detached property comprises of twenty-three single occupancy bedrooms, of which sixteen have en-suite facilities; three doubles; a separate dinning room; large main lounge with a conservatory/smoking room attached; kitchen; laundry and a sluice rooms; two offices; a staff room; and passenger lift. The garden at the rear of the property is mainly laid to lawn, has a large patio area, and is well maintained. The provider ensures information about the service, including what facilities they offer, the range of fees charged (i.e. £389 to £550 per week), and CSCI reports, are all made available to prospective service users and their representatives through the homes Statement of purpose, Service users guide and terms and conditions of occupancy contracts. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used to inform this key inspection report came from a wide variety of sources, including the homes most recent inspection reports, the Commission for Social Care Inspections’ (CSCI) database, and information gathered during a site visit to the home. The unannounced site visit was carried out over seven hours between 10.30am and 5.30pm on Wednesday 3rd May 2006. During which time four service users, the homes registered and deputy managers, and a newly appointed support worker, were all spoken with at length. All four service users met helped complete the CSCI’s new ‘have your say’ surveys regarding their experiences of life at the home. The manager was also asked to fill out a Pre-Inspection Questionnaire and an Equalities survey regarding the ethnic origins of the current service users and staff team. The remainder of the site visit was spent examining the homes records and touring the premises. No additional visits have been carried out by the CSCI in respect of this service in past twelve months and the one complaint investigated by the Commission during this time was not upheld. What the service does well: What has improved since the last inspection? Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 6 The home has succeeded in addressing the vast majority of the requirements identified in its last CSCI report. The Commission acknowledges the manager’s comment that ‘significant progress has been made by the service in the past six months to address many of its shortcomings’. Prospective service users individual aspirations and needs are more thoroughly assessed prior to admission and care plans contain far more detailed information about each service users unique emotional health care needs, as well as the support they will require to have them met. As recommended in the homes previous CSCI report the manager has introduced an activities book to record all the social, leisure and recreational pastimes the service users choose to engage in. The vast majority of service users spoken with said they had all seen a marked improvement in the number and variety of activities on offer at the home especially enjoyed the weekly visits of the music and massage therapists. Staff recruitment procedures are far more robust ensuring no new members are permitted to commence work there before being checked against the Protection Of Vulnerable Adults (POVA) Register. Formal supervision sessions of staff by the manager and staff meetings are also being held at more regular intervals. Finally, the homes arrangements for ensuring suitably qualified engineers test all the homes fire equipment on a more frequent basis has improved. The fire risk assessment for the building has also been reviewed in the past twelve month and updated accordingly. What they could do better: Overall, key policies and procedures relating to safety are in place, but there is variable implementation in practice and the manager acknowledges that basic provision at the home must be improved in a number of clearly identifiable ways: The home has repeatedly failed to ensure care plans are continually reviewed and up dated accordingly to reflect service users continually changing needs. All ‘unwanted’ medication is not always being returned to the dispensing pharmacist in a timely fashion resulting in large quantities of discontinued medicines being left to stockpile in the home. Overall training is adequate but needs to be improved to ensure the staff team have the necessary knowledge and skills to meet the joint needs of the service users and administer first aid, handle medication safely and are aware of equality and diversity issues that affect the home. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 7 The homes self-monitoring arrangements must also be improved to ensure the findings of any stakeholder satisfaction questionnaires and unannounced inspections the providers undertake are published for all interested parties, including services, their representatives, and the CSCI, to view. Finally, the home has failed to ensure appropriate records are maintained of all the fire alarm checks and fire drills conducted by staff working there in accordance with basic fire safety standards. Furthermore, under no circumstances must the home continue to prop open fire resistant doors, preventing their automatic closure in the event of the fire alarm being sounded. 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`s Home DS0000025811.V292421.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 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 the following standard(s): 3 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager demonstrate that all prospective service users are only admitted to the home on the basis of a full needs assessment ensuring no one moves in without having been assured their needs will be met. EVIDENCE: The service has only accepted one new referral since it was last inspected in December 2005. Documentary evidence was available on request to show that the individuals Care manager and the home had assessed jointly the needs of the homes most recent admission. The assessment was thorough and covered every aspect of the individual’s personal, social, and health care needs, including their mental state and cognition, mobility and history of falls, and specific religious beliefs. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 7, 8, 9 & 11 Quality in the outcome area is poor. This judgement has been made using available evidence including a visit to this service. Significant progress has been made by the home to improve its care plan format to enable service users to feel confident their plans will generally reflect not only their personal and social needs, but also their emotional and physical health care needs as well. However, care plans are still not being reviewed at regular intervals and up dated accordingly to accurately reflect service users continually changing needs and aspirations. The homes arrangements for dealing with medicines are not sufficiently robust to protect the service users from avoidable harm and/or abuse. Suitable arrangements are in place to enable service users to feel confident that at the time of their death, staff will treat them and their family with the utmost sensitivity and respect. EVIDENCE: Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 11 All four Care plans inspected contained far more detailed information about each service users current mental ill health needs and what support they required to meet them. Documentary evidence was also available on request to show that management strategies had been established to enable staff to deal more effectively with any identified risks, including falls and continence issues. None of the four Care plans examined had been reviewed in the past month, despite this being identified as a major shortfall in the homes two previous inspection reports. The manager has agreed to establish a care plan review record which service users designated keyworkers will be required to complete on a monthly basis. All four service users spoken with at length said they were always invited to attend their annual care plan reviews, but were not involved in up dating them on a monthly basis with their keyworkers. All four care plans inspected contained detailed information about service users unique physical and emotional health care needs and entries in the homes visitors book revealed that community based General Practitioners, District and Psychiatric Nurses, and dentists regularly visit the home. The homes accident book revealed that service users had been involved in five accidents since December 2005, none of which had resulted in any major injuries or hospital admissions. The home continues to use a recognised monitored dosage system for handling medication, despite changing the Chemist it usually deals with. Three service users Medication Administration Records (MAR) sampled at random had been appropriately maintained in March 2006, but none of the medicines received in following month had been signed for by staff who are meant to check them in. A similar shortfall was identified in the homes previous inspection report. Furthermore, having asked a member of staff to open a locked metal cupboard upon which the homes medicines cabinet is currently situated it was concerning to note that large quantities of discontinued medicines that had not been returned to the dispensing pharmacist were being inappropriately stockpiled. All Controlled drugs held in the home are securely stored in a locked cabinet and two suitably trained staff always sign for its use. These arrangements in themselves meet the standard, but the manager should nevertheless give serious consideration to obtaining a separate Controlled Drugs register for staff to counter sign each time they handle this type of medication as recommended by the Royal Pharmaceutical Society of Great Britain. Clear guidelines for the appropriate use of ‘as required’ (PRN) medication were available on request and the manager said none of the service users currently residing at Mary’s Home are willing to self-medicate. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 12 Since December 2005 three service users have sadly passed away. All the care plans inspected documented the spiritual needs of the service users and it was evident from comments made by the manager that wishes regarding dying and death would be respected by the home. One service user met said they had attended the funeral of one of the individuals who had recently passed away along with several members of staff. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 12, 13, 14 & 15 Quality in the outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The social, leisure, and recreational opportunities the services users have to engage in have improved in the past year, are well managed, and provide daily variety and stimulation. Dietary needs, including specific cultural ones, are also well catered for and the meals the service users receive are in the main nutritionally well balanced, appealing, and varied. EVIDENCE: The manager recently introduced an activities book, which revealed that the service users had far greater opportunities to participate in stimulating activities of their choice. All the services users met commented favourably about the number and variety of activities now on offer and all said they had seen a marked improvement in the past year. One service user said that although they chose not to join participate in any of the organised events they were always made aware when and where they were happening. Activities coordinators now visit the home twice a week and one service user said they particularly looked forward to the massage therapy sessions, while another Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 14 said they liked the music and movement classes. A lot of the service users artwork was displayed on the dinning room wall for all to view. The minutes of the last three service users meetings revealed that several people had expressed a wish to go on day trips to London and the coast this summer. The manager said arrangements for these trips to place over the forthcoming months were in the process of being planned and progress on this matter will be assessed at the homes next inspection. All the service users met said there were not aware of any restrictions regarding what time they got up, went to bed, or when their friends and relatives could visit them. One service user said they had an advocate from Mind to represent their interests. Leaflets about how service users and their relatives could contact other external advocacy groups were also available in the home. All the service users spoken with at length agreed that one of the things they liked about living at Mary’s Home was the quality of the meals provided. Lunch was served at 12.30 in the recently redecorated dinning room and the atmosphere felt extremely relaxed and unhurried. A trolley with a choice of three main courses on, which matched the published menu options conspicuously displayed on the notice board, all looked and smelt extremely appetising, well cooked, and hot. Dishes served up on the day included steamed fish, meatballs and vegetable stew, which all came with a choice of mixed vegetables, mashed swede and boiled potatoes. A variety of condiment, that included salt and pepper, were all laid out on a number of small tables in the dinning room that sat a maximum of four people each. Specific dietary needs are also well catered for and the published menus took into account certain service users specialist diabetic, cultural, and vegetarian needs. For example, goat curry is often advertised on the weekly menus to meet the dietary preferences of some of the homes black British Caribbean service users. During the course of the visit a service user came to see the manager in her office to check whether his order for salt fish had arrived yet. The individual went onto to explain that the manager would often arrange a special delivery of salt fish for him to prepare some Caribbean style dishes for everyone to enjoy. It was also noted that the kitchen door remained open throughout the course of this visit and two service users who had both chosen to have a late lunch were observed asking the cook to heat up food which had been specially saved for them. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 16 & 18 Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the homes arrangements for dealing with complaints ensures the service users feel confident that their views and complaints will be listened to and acted upon, although more detailed information about any action taken by the home in response must be recorded. The homes procedures for dealing with allegations of abuse are sufficiently robust to minimise the risk of service users being abused. EVIDENCE: All the service users spoken with at length said that staff usually took account of their views and they knew who they could speak to if they were unhappy with anything at the home, which included the manager, their keyworker or other members of staff they felt able to trust. The homes complaints log revealed that all the concerns raised by service users in the past twelve months, the majority of which had been made by the same individual, had all been investigated to the complainant’s satisfaction. However, the record was not always sufficiently detailed to enable anyone authorised to inspect it to determine whether or not appropriate or indeed any action had been taken by the home in response. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 16 There have been no allegations of abuse made within the home in the past twelve months and the manager confirmed that all sixteen members of her current staff team have attended vulnerable adult abuse training, although very little documentary evidence of this was available on request. Care plans now contain far more specific guidance to enable staff deal more effectively with incidents of aggression and the word ‘restraint’ has now been removed from the homes dealing with aggression policy as surplus to requirements (i.e., It contravenes the homes underpinning ethos and consequently staff are not suitably trained to use physical intervention techniques). Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 19, 25 & 26 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, the home is well maintained ensuring the service users live in a safe and comfortable environment. However, if based on an assessment of risk the manager deems it necessary to continue locking the fire resistant front door, and then it must be fitted with a suitable release mechanism that automatically opens it in the event of the fire alarm being activated. EVIDENCE: On arrival three service users were making the best of the good weather were sitting on garden chairs or just lying on the newly laid lawn at the rear of the property. Several others were observed either smoking in the new conservatory or just sitting watching television in the main lounge. The atmosphere in these newly created communal areas felt extremely relaxed and homely. Service users met said they were not aware of any restrictions placed on them regarding where they could go in the home and moat said on the whole they Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 18 could come and go as they pleased. However, it was noted that the front door remained locked during the course of the visit which meant service users and their visitors all had to find the member of staff who held the key to enable anyone to leave the building. The manager said this was to minimise the risk of service users going absent without authorisation, although conceded that no assessments identifying such a risk had ever been undertaken by the home. Furthermore, as the front door is a fire exit it should remain unlocked at all times unless it is fitted with a suitable device that will open it automatically in the event of the fire alarm being sounded. A rather tatty footstool that appeared to be very popular with service users relaxing in the lounge must either be reupholstered or replaced. The temperature of water emanating from a hot tap attached to a ground floor bath in the new wing was noted to be a safe 40 degrees Celsius at 14.45. All the service users spoken with at length said the home was always kept clean and fresh by the staff. The home has a contract for dealing with clinical waste and staff spoken with were all aware how this type of waste should be disposed off. Adequate supplies of latex gloves and yellow and black plastic bags for this purpose were found stored in various locations throughout the home. Staff getting ready to help one service user with their personal care needs were observed wearing appropriate protective clothing, which included plastic gloves and aprons. Laundry is never taken through areas where food is stored, prepared, or eaten. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 19 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole sufficient numbers of suitably competent and qualified staff are employed on a daily basis to ensure the individual and joint needs of the service users are being met, although more staff will need to up date their first aid, equal opportunities and medication training. The home operates a thorough recruitment procedure, which is sufficiently robust to minimise the risk of service users being harmed or abused by individuals who are ‘unsuitable’ to work with vulnerable adults. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 20 EVIDENCE: It was noted that a total of three support workers, the homes registered and deputy managers, a cook, and a cleaner, were all on duty over the course of this unannounced site visit, which matched the staff duty roster for that day. The number and skills mix of both the early and late shifts seemed adequate to meet the assessed needs of the service users currently residing at Mary’s Home. The homes largely female staff team comprises entirely of people with black British African or Caribbean backgrounds, which only reflects less than 20 of the service users ethnic origin, as the majority describe themselves as either white or Asian British. The manager conceded that while the ethnically diverse mix of her staff is fairly reflective of the area in which the home is located it does not accurately reflect the ethnic backgrounds of most of the service users currently residing at Mary’s Home. The manager has agreed to be mindful of this ethnic and cultural imbalance when she next recruits new members of staff. Furthermore, all staff must receive equal opportunities and diversity awareness training. Some progress has been made to ensure that over a third of the homes current support workers had now either achieved an National Vocational Qualification Level 2 or above in care or had enrolled on a suitable course. The manager is confident that at least 50 of the homes current staff team will be studying for this qualification by July 2006 to meet government training targets for support workers. One of the homes most recent recruits was spoken with at length and said they were still in the process of completing their induction, which they started on their first day at the home. They went onto to say the induction included principles of care, the needs of the services users and safe working practices, such as what to do in the event of a fire. Documentary evidence was available on request to show that sufficient numbers of the current staff team had received accredited training in food hygiene and supporting people with mental ill health in later life. However, not enough staff are suitably trained to administer first aid on each shift and all those currently authorised to handle medication in the home must attend refresher courses. Staff records revealed that the home had experienced relatively low levels of staff turnover in the past six months. Both the staff files for the homes most recent recruits were examined in some depth and found to contain; two written references, one of which came from their last employers; up to date Criminal Records and Protection Of Vulnerable Adults checks, which were both obtained before the individuals was permitted to commence their employment at the home; and a copy of their passports, as proof of identity; and Home Office approved work permits for non EEC citizens. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 21 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in the outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes self-monitoring arrangements for assuring quality, which includes stakeholder satisfaction questionnaires and unannounced inspections by the providers, are not sufficiently robust to enable service users, their representatives, and the CSCI, to measure how successfully or not the service has been at achieving its stated aims and objectives. Staff are appropriately supervised at regular intervals. Arrangements for promoting the safety of the service users, their guests and staff are currently not sufficiently robust and action is urgently needed to improve the homes fire safety record keeping and the periodic testing of related equipment. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 22 EVIDENCE: The registered manager has yet to achieve the care component of her NVQ 4, but is confident with only two units to go she will have been awarded this qualification by September 2006. Documentary evidence was available in the form of minutes to show that three service users meetings had been held in the home since December 2005. These meetings had been well attended by the service users and staff on duty at the time and had covered a wide variety of topics, including food, in house activities, and day trip destinations. The home has an equal opportunities policy document in place although the manager conceded that it had not been reviewed for many years. The policy will need to be updated to include more detailed information about Britain’s anti-discrimination legislation, (e.g. Race Relations, Sex, and Disability Discriminations Acts) and the homes procedures for dealing with racial harassment and abuse occurring between service users; between staff; and by service users on staff or staff on service users. Copies of reports following unannounced inspections of the home by the registered providers or their representatives are not being forwarded to the Commission at regular intervals. As neither of the co-owners are in operational day-to-day control of the home a responsible individual who is not directly concerned with the conduct of the service must be appointed to carry out these unannounced monthly inspections, prepare a report of their findings and supply the Commission and the registered amanger with a copy. The person carrying out these visits must interview the service users, their representatives, and staff; inspect the premises; and examine the homes incident and complaints records. Documentary evidence was available on request to show that the manager had created a variety of stakeholder satisfaction questionnaires for service users, their relatives and professional representatives, in order to ascertain their views about the quality of the service provided at Mary’s Home. The manager said a dozen surveys had already been returned and she planned to wait a little longer for a few more to come back before publishing the results in September 2006. The balances recorded on two service users financial sheets inspected at random matched the amount held by the home on their behalves. Staff record all the financial transactions between themselves and service users and receipts are always obtained. Service users money being looked after by the home was securely stored away in a lockable space, although it is recommended that such large quantities of cash are not held in the home from now on in order to minimise the risk of theft. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 23 Documentary evidence was available from four staff files inspected at random to show that they had all received at least two formal supervision with a senior member of staff since January 2006. A new member of staff who was informally interviewed confirmed that they had received at least one supervision session with the manager since starting work at the home. They were also very clear about their fire safety responsibilities and knew where the nearest fire exit, break glass point, and fire extinguisher were in respect of the main lounge. Up to date certificates of worthiness were in place as evidence to show the homes gas installations and fire alarms system had been tested by suitably qualified engineers in the past twelve months. A fire risk assessment for the building was also available on request, which had recently been reviewed, and a copy of the homes fire procedure was conspicuously displayed in the entrance hall. However, further inspection of the homes other fire records revealed that the fire alarm system had not been tested since 6/04/06 and no fire drills carried out in 2005/6. The manager was adamant that the fire alarm system continues to be tested on a weekly basis by staff and that at least two fire drills were undertaken in 2005, in line with the local fire authorities guidance. The manager acknowledges that the home has failed in its duty of care to record these activities as proof of compliance with vital health and safety regulations. It was also noted during a tour of the premises that a damaged sound activated release mechanism attached to a fire door in the main lounge ground was being propped open with a rubber wedged contrary to fire safety regulations. Finally, Certificates of worthiness showed that the homes annual portable electrical appliances and fire extinguisher checks were also over due. Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 1 X 2 3 X 1 Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15(2) Requirement Timescale for action 10/05/06 2. OP9 13(2) 3. OP9 13(2) 4. OP16 17(2), Sch 4.11 Service users and their designated keyworkers must be involved in reviewing care plans on a monthly basis and updating them accordingly to reflect any changing needs. Documentary evidence of these internal review meetings must be made available on request. Previous timescales for action of 1st June 2005 & 1st January 2006 both not met. Immediate Requirement Notice served. All ‘unwanted’ medication must 05/05/06 be returned to the dispensing pharmacist as soon as practicable. Immediate Requirement Notice served. All medicines received by the 01/06/06 home must always be ‘checkedin’ by suitably trained staff and a signed and dated record kept. Previous timescale for action of 1st January 2006 not met. Staff must appropriately 01/06/06 maintain more detailed records regarding the homes response to any complaint and/or concern made about its operation. DS0000025811.V292421.R01.S.doc Version 5.1 Mary`s Home Page 26 5. OP18 6. OP19 7. OP19 8. OP30 9. OP30 10. OP30 11. OP32 12. OP33 Documentary evidence of staff attendance of recognising, preventing and reporting vulnerable adult abuse courses must be kept in the care home at all times. 13(4) & If based on an assessment of 23(4)(b) risk the manager still deems it necessary to lock the front door it must be fitted with a keypad device that will automatically release in the event of the fire alarm being activated. 23(2)(c) The rather worn out foot stool used in the main lounge must either be reupholstered or replaced. 18(1) & All staff must receive equal 19, Sch opportunities and diversity 2.4 awareness training. Documentary evidence of this training must be kept in the home and made available for inspection on request. 13(4)(c) & At least one member of staff who 19, Sch is suitably trained to administer 2.4 first aid must be on duty at all times, including at night. 13(2), All staff currently authorised to 18(1) & handle medication in the home must attend refresher courses in 19, Sch 2.4 the safe administration of medication in a residential care setting. 12(4) (5) The home must review its Equal opportunities policy and up date it accordingly to reflect current anti-discrimination legislation and include a statement about how the home deals with incidents of racial harassment and abuse. 26(2), The responsible individual who is (3), (4) & assigned the task of carrying out (5) unannounced inspections of the home on behalf of the registered providers must interview service users and staff; inspect the DS0000025811.V292421.R01.S.doc 19, Sch 2.4 01/07/06 01/06/06 01/07/06 01/08/06 01/08/06 01/08/06 01/07/06 01/06/06 Mary`s Home Version 5.1 Page 27 13. OP33 14. OP38 15. OP38 16. OP38 premises; examine records of events and complaints; and prepare a written report for the Commission each month. 24(1) The results of any stakeholder surveys/satisfaction questionnaires undertaken by the home to ascertain service users, their relatives and professional representatives views about the quality of the service provided must be published on an annual basis as part of an effective quality assurance system. Previous timescale of the 1st February 2006 not met. 17(2), Staff must appropriately Sch 4.14 maintain records of any fire & 23(4)(c) alarm tests and fire drill practices conducted in the home. 23(4)(c) The damaged sound activated release mechanism attached to the fire door in the main lounge must be repaired as a matter of urgency. In the interim this door must not be propped open with a wedge. 13(4) & Suitably qualified engineers must 23(4)(c) test all the homes fire extinguishers and portable electrical appliances on an annual basis. 01/09/06 01/06/06 01/06/06 01/06/06 Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 28 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 OP9 Good Practice Recommendations The manager should give serious consideration to obtaining a separate Controlled Drugs register to record the receipt, administration, and disposal of all Controlled Drugs and store them in a locked metal cupboard within the homes medication cabinet. The manager should be mindful of the cultural and ethnic imbalance that currently exists between her staff team and the service users when she next new recruits. 50 of all care staff working at the home should have obtained an NVQ level 2 or above in care, or at least a time specific plan established by the end of 2005 identifying when the rest of the homes staff team will have commenced this training. The manager should have achieved an NVQ level 4 in management and care by the end of 2005. Service users money looked after by the home should not be stored in such large quantities. 2. 3. OP27 OP28 4. 5. OP31 OP35 Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston 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 Mary`s Home DS0000025811.V292421.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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