Inspection on 09/12/05 for Mary`s Home

This inspection was carried out on 9th December 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 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 Unannounced Inspection 9th & 12th December 2005 09:45 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.V257147.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V257147.R01.S.doc Version 5.0 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 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.V257147.R01.S.doc Version 5.0 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. 28th April 2005 Date of last inspection Brief Description of the Service: Mary’s Home is a privately owned and run residential care home that specialises in providing personal care and support for up to twenty-nine generally older adults with a past or present experience of mental ill health. The Commission for Social Care and Inspection (CSCI) has also approved a variation to allow six specified younger service users (i.e. under the age of 65) to be accommodated there providing the home continues to be able to meet their assessed needs. The youngest service users currently residing at the home are all in their early to mid fifties. Since the homes last inspection in April 2005 Regina North has successfully undertgone a ‘fit’ person interview with the Commission to become the registered manager of this service. Regina has been in operational day-to-day control of Mary’s home for just over two years now. Dr Edward Appah and Mrs Helen Appah remain the registered co-owners of the home. There has been no significant changes made to the property since April’05 when the number of places the home offered more than doubled. The home now comprises of twenty-three single occupany bedrooms, sixteen of which have ensuite facilities, and three doubles. Sufficient numbers of toilet and bathroom/shower facilities are located throughout the house near service users bedrooms and communal spaces. Communal areas consist of a seperate dinning room, a large main lounge with a conservatory/smoking room attached, kitchen, laundry and sluice rooms, two offices, a staff room, and passenger lift. The large garden at the rear of the property is mainly laid to lawn, but does include a large patio area with some garden furntiure. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out over two half days on a Friday morning and Monday afternoon in mid December. It took six hours in total to complete. Since the homes last inspection was carried out in April 2005 the Commission has not received any comment cards in respect of this service. The majority of this inspection was spent talking to the homes recently registered manager, her deputy, the senior in charge of the early shift and three service users at length, although around a dozen or so service users were met at various times throughout the two visits, albeit briefly at times. The rest of the time was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past eight months. What the service does well: All three of the service users spoken with at length said they liked living at Mary’s home as they got on well with most of the other service users and staff. Staff on duty at the time of these visits were observed interacting with the service users in a very respectful and courteous manner. A lot of the service users met said one of the best things about living at Mary’s home was having the freedom to choose how much time you spent in the privacy of your own bedroom or with others in the various communal spaces, depending on your mood. One of the homes most recent admissions said Mary’s home compared extremely favourably with their previous placement as they shared a lot in common with most of the other service users who were about the same age as her. They also said “the place was always kept clean and in ‘tip top’ condition”. Staff records revealed that the homes current staff team has not significantly changed in the past twelve months, ensuring the service users receive continuity of care from a relatively small group of experienced support workers who are familiar with their unique needs, wishes and preferences. Finally, the atmosphere in the home throughout the course of this six hour inspection split over two half days felt extremely relaxed and homely, despite the significant changes made to the number, size and layout of the home in the past twelve months. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Progress has clearly been made by the home to improve the quality of the service is provides in the past twelve months, although the positive comments made overleaf notwithstanding the home still needs to improve its practice in a number of core areas. The most significant areas of concern are listed below: Needs assessments undertaken by the home prior to a service users admission must always be kept in the home. Care plans should contain more specific details about how the home intends to plan for and met each service users unique psychology needs and deal with incidents of verbal aggression, including what might ‘trigger’ such behaviour. These plans also need to be reviewed on a more frequent basis and up dated accordingly. The homes current arrangements for the recording, handling and safekeeping of all medicines kept by the home, including Controlled drugs and ‘as required’ (PRN) medication, are woefully inadequate and need to be tightened up as a matter of urgency. The homes recruitment procedures also need to be tightened up to ensure no new members of staff commence working at the home before satisfactory Protection Of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks have been completed. The manager is reminded that only in ‘exceptional circumstances’ may a person start without a completed CRB providing certain conditions are met and the Commission approves the decision. The Commission considers it extremely poor practice and will only allow a person to start without a CRB if the shortage of staff is so severe the service users are being placed at risk. The homes arrangements for consulting service users and staff about the homes operation also needs to be improved and the minutes of residents and Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 7 staff meetings recorded. Some progress has been made by the manager with regard the number of supervision sessions each member of staff receives, but further improvement is still required if everybody is to have at least one every two months. Finally, the homes fire alarm system and gas installations periodic tests are overdue and the homes fire risk assessment for the building needs reviewing. 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.V257147.R01.S.doc Version 5.0 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.V257147.R01.S.doc Version 5.0 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): 1&3 Significant progress has been made by the manager to improve the homes Statement of purpose and guide to ensure prospective new service users and their representatives are supplied with all the information they need to know to make an informed decision about whether or not to move in. The homes admission procedures are in the main sufficiently robust to ensure service users needs are thoroughly assessed before being allowed to move in, although records of these assessments undertaken by the home were not always available on request. It is essential that these records are kept in the home at all times to enable anyone ‘authorised’ to inspect these assessments to determine whether or not the home is capable of planning for and meeting a prospective new service users assessed needs. EVIDENCE: As required in the homes previous inspection report the manager has amended the homes Statement of purpose and service users guide. These documents now contain all the information required by the Care Homes Regulations (2001). It was positively noted that the homes Statement of purpose was last reviewed in September 2005 and updated accordingly to reflect any changes. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 10 There have been six new admissions since April’05 and the home currently only has one vacancy. 50 of the files in respect of the homes most recent admissions were sampled at random and it was noted that although all three contained a community psychiatric nurse assessment of need only two out of three had been thoroughly assessed by the home. The manager is reminded that no prospective service users must be allowed to move in before all their personal, social and health care needs have been fully assessed by a person suitably qualified to do so (i.e. the homes manager or senior member of staff). One of the homes most recent admissions spoken to at length during the course of this inspection said they “enjoyed living at Mary’s home, which compared very favourably with their last place of residency, and that they got on extremely well with most of the other service users and members of staff”. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10 & 11 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified, planned for and met. However, the homes current arrangements for the recording, handling, and safekeeping of medication are woefully inadequate and do not offer the service users sufficient protection from harm and/or abuse. EVIDENCE: Three care plans (Just over 10 ) were sampled at random and as required in the homes last inspection report they all contained far more detailed information about each service users unique social interests, food preferences and assessments of risk, especially those associated with service users health care needs (e.g. epilepsy, falls, diabetes and incontinence). Overall, significant progress had been made by the home to improve its care plan format, although the recently registered manager acknowledges that there still a great deal of room for improvement. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 12 Plans must set out in greater detail how each service users current and anticipated specialist mental ill health needs will be met (for example through positive planned interventions; rehabilitation and therapeutic programmes; structured environments; development of language and communication; adaptations and equipment; and one to one support). Furthermore, none of the care plans sampled had been reviewed in the past month, contrary to National Minimum Standards. One of the homes most recent admissions had still not had their care plan or ‘trial’ period of residency reviewed despite arriving over five months before. Having discussed this matter with the manager it was agreed that because the vast majority of the service users were currently aged either just under or over 65 then it would be acceptable for care plans to be reviewed on a quarterly basis, in line with the Care Programme Approach for people with a past or present mental illness, as opposed to monthly for older people with dementia. The manager was reminded that the outcomes of all these meetings, including the annual formal review must always be recorded and made available for inspection on request. The homes accident book revealed that both the accidents that had occurred in the home since May’05 had been falls. Both involved service users and no significant injuries were sustained, consequently there have been no unplanned admissions to hospital in the last eight months. There have been two planned admissions to hospital in the same period for two service users whose physical health had deteriorated. None of the service users have experienced pressure sores in the past twelve months. Specialist equipment in the form of a catheter is being used by one of the homes most recent admissions. A district nurse is the only person authorised to change it, although staff must empty it at least every three and a half hours or so. The senior in charge of the early shift on the first day of this inspection was aware how often the catheter needed to be emptied. The manager said that various community based psychiatric nurses continue to visit the home on a fortnightly basis to review their clients. The home continues to use a recognised monitored dosage system and records kept of all medicines administered in the home in the past four weeks were appropriately maintained. However, it was noted that staff ‘authorised’ to handle medication in the home had failed to sign the appropriate documentation for the last patch of medication delivered to the home in December 2005. Furthermore, despite the availability of Controlled drugs in the home, these were not being correctly stored in a separate locked space within a locked metal cupboard and nor was a specialist Controlled drugs register being counter signed by two suitably trained staff who must witness each other every time this type of medication is received into the home, administered and/or disposed of. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 13 It was also noted that some ‘as required’ (PRN) medication was being administered on a daily basis and that no protocols for its specific use, which should set out clearly under what circumstances this type of medication should be used, for how long, and ultimately who is responsible for authorising its use. This particular service users’ GP needs to be consulted as a matter of urgency and their current medication regime reviewed before any ‘as required’ protocols are drawn up. Finally, although it was positively noted that as required in the homes previous inspection report one service user who was willing and capable of self administering their own medication has been given the opportunity to do so, an assessment of the risks involved had not been undertaken by the home, or at least recorded. The manager said that the individual concerned had been provided with a lockable space in their bedroom to securely store there medication and that arrangements were in place for the home to discreetly monitor the situation. Three service users met during the course of this inspection said staff always knock on their bedrooms doors to ask their permission before entering. During a tour of the premises the shift leader on duty at the time was observed politely asking the occupants of several bedrooms permission to enter, and in one case waiting for a service user to open their bedroom door as no verbal response had been received. It was noted that all three of the care plans sampled at random, including one for the homes most recent admission, documented their religious and spiritual needs, as well as their wishes in relation to dying and death. The manager agreed that it was easier to ascertain this type of extremely sensitive information prior to admission. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 the following standard(s): 12 & 15 Significant progress has been made by the home to ensure service users have the opportunity, at least, to participate in a number of planned social, leisure and recreational activities. Meals are nutritionally well balanced and provide daily variation and interest for the people living in the home. EVIDENCE: Half a dozen or so service users spoken with at various times throughout the course of this six hour inspection all said they found the lifestyle they experienced at Mary’s home in the main matched their expectations and satisfied their social, religious and recreational interests. During a morning tour of the premises several service users who were at home were observed relaxing in the dinning room, listening to music in the main lounge or having a cigarette in the conservatory. One service user met in their bedroom, who was watching a film on television at the time, said one of the best things about living at the home was having the freedom to spent as much time as you wanted in your own company. This same person also owns a pet budgerigar, which they keep in their bedroom. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 15 Staff and service users met also said that an activities coordinator regularly visits the home and holds music and exercise classes. Furthermore, the manager and a senior member of staff have recently attended a reminiscence course and plan to arrange regular reminiscence sessions, which have already commenced. One service user met said they particularly enjoyed the reminiscence sessions, which had brought back a lot of memories for them. The home continues to arrange Christian services for anyone who chooses to participate each morning in the main lounge. This summer several of the service users said they had been on a day trip to Brighton that had been arranged by the homes deputy manager (aka. the owners son). It was positively noted that conspicuously displayed on a notice board in the main lounge was information about the homes forthcoming Christmas party, which was going to be held on 20th December 2005. The number and range of activities the service user have the opportunity to participate in appears to have significantly improved in the past twelve months, although the manager acknowledges that staff are not particularly good at recording these events in service user daily diary notes. It is therefore recommended that the manager should consider introducing a separate activities book to record the entire social; leisure and recreational pastimes the service users choose to engage in. Having arrived just before lunch on the first day of this inspection several service users had begun to congregate in the dinning room. All six of the service users spoken with as a group were aware that it was fish for lunch that day. Salt and pepper condiments were laid out on most of the tables in the dinning room. One service user who was a vegetarian said they were well catered for and that there was always a vegetarian option on the menus. Three service users spoken with in the conservatory said you always had a choice at breakfast of toast or cereal, which always came with a pot of tea or coffee. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 the following standard(s): 16 & 18 The service users are confident that any concerns they have about the homes operation will be listened to and acted upon by staff in accordance with the homes complaints procedures. Overall, the homes arrangements for dealing with allegations of abuse or aggression are sufficiently robust to protect the service users, so far as reasonable practicable, from avoidable harm, although the homes non physical intervention policy and guidance for dealing with specific incidents of verbal aggression still need to be amended to bring them in line with current good practice. EVIDENCE: The home has received ten complaints in the past eight months from the same service user about concerns they have about another service user continually harassing them for cigarettes and staff not cleaning his bedroom. The aforementioned service user who was at home at the time of this inspection declined to be interviewed about his concerns, but according to the homes complaints log and comments made by the manager all the aforementioned issues have been resolved to his satisfaction. Nevertheless, the manager conceded that historically these issues have tended to be raised time and time again by this individual and it was therefore disappointing to note that the action all the interested parties had agreed to take to minimise the occurrence of such events had not been written up and recorded in their care plan. Half a dozen or so of the service user met said staff were good listeners and were always on hand to offer them advice and support about any concerns or complaints they may have. During the course of this inspection several service Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 17 users came to the ground floor office to ask the staff and manager advice about a wide range of topics that varied from financial matters to public transport times. In the past twelve months no allegations of abuse have been made within the home and as required in the homes previous report sufficient numbers of the homes staff have now attended a recognising, preventing and reporting abuse course, in accordance with vulnerable adult protection guidance. However, more specific guidance to enable staff to deal with incidents of verbal aggression, including what tends to ‘trigger’ this type of behaviour, still needs revising. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 the following standard(s): 19, 20 & 25 The home provides the service users with a comfortable, clean and safe environment in which to live. EVIDENCE: There have been no significant changes made to the homes physical environment since the building work on the new extension was completed. A couple of service users met said they liked the increased amount of communal space the new enlarged lounge, dinning room and conservatory provided them. Three service users who were all enjoying a cigarette in the conservatory on the second day of this inspection said this was proofing a popular place for all the homes smokers to sit, relax and have a chat. All the bedrooms are centrally heated and radiators in communal areas are all covered. The home was pleasantly warm throughout the course of these visits and all the service users met said they were never cold. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 19 Having used a thermometer to test the temperature of hot water emanating from a shower outlet and tap attached to a ground floor bath, both were found to be close to a safe 43 degrees Celsius. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 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 Overall, sufficient numbers of suitably experienced, qualified and competent staff are employed to meet the health and welfare needs of the service users. However, the homes arrangements for recruiting new members of staff are not sufficiently robust to, so far as reasonably practical, protect the service users from being harmed and/or abused by individuals who are ‘unfit’ to work with vulnerable adults. EVIDENCE: It was positively noted that in accordance with staffing levels previously agreed with Commission at least four members of staff, excluding the homes deputy manager, were all on duty at the time of the first day of this unannounced inspection. Staff training records revealed that only two members of the homes current staff team have achieved a National Vocational Qualification in Care - Level 2 or above, which represents no change since the homes last inspection, although the manager is confident that another member of staff would have achieved this qualification by the end of 2005. Nevertheless, even if this is achieved the home is still woefully short of meeting the National Minimum training targets for care workers (i.e. At least 50 of care staff achieve an NVQ in care by the end of 2005). Plans to rectify this training shortfall must be established as a matter of urgency. Progress on this issue will be assessed at the homes next inspection. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 21 The home continues to experience relatively low levels of staff turnover and consequently only two new members of staff have needed to be recruited in the past eight months. The new member of staffs’ files was examined in some depth and found to contain the terms and conditions of their employment; proof of their identities, which included a recent photograph; two written references, including one from their previous employers; and Home Office approved working visas. However, having cross referenced the date one of these new members of staff started working at the home against the date their Protection Of Vulnerable Adults (POVA) First check was completed it became immediately apparent that this particular individual had been working unsupervised with service users at the home for at least a month without being checked the POVA register. Furthermore, although this individual had applied for their Enhanced Criminal Records Bureau (CRB) check before starting work at Mary’s’ home it was nevertheless incomplete and was still being processed at the time of this inspection. The registered manager must ensure that under no circumstances may new members of staff commence working at the home before a POVA first check has been completed. Furthermore, the manager is reminded that only in ‘exceptional’ circumstances’ may new members of staff commence their employment while their CRB is still being processed; and even then it is considered extremely ‘poor practice’ and is subject to certain conditions being met, which the Commission must approve. The conditions that must be met before the Commission will even consider allowing a new member of staff to commence their employment without a satisfactory Enhanced CRB being completed are as follows: The new member of staff must have applied for an Enhanced CRB; have a POVA First check, along with all the other documents specified in Schedule 2 of the Care Homes Regulations (2001); never work alone with service users and have designated co-worker to supervise them at all times during their probationary period. It was positively noted that as required in the homes previous inspection report sufficient numbers of the current staff team had recently attended suitable training courses in fire safety and working with older people who have experienced past or present mental ill health. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 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, 36 & 38 The homes arrangements for ensuring service users and staff views about the service are taken into account and that they are actively encouraged to participate in its day-to-day running needs to be improved by ensuring all service users and staff meetings are minuted and the results of quality assurance surveys published. Not all the homes staff team are receiving regular supervision sessions with a suitably qualified senior, which could have an adverse affect on the standard of care staff provide the service users. In the main the homes health and safety arrangements are sufficiently robust to ensure potential risks to service users, their guests and staff are, so far as reasonably practicably, minimised, although the homes fire alarm system and gas installations need to be tested on a more frequent basis, and fire risk assessment for the building reviewed. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 23 EVIDENCE: Since the homes last inspection carried out in April 2005 the homes acting manager, Regina North, has successfully undergone a ‘fit’ person interview with the Commission and is now the homes registered manager. Regina North has been in operational day-to-day control of the home for over two years and is still in the process of studying for her registered managers award, which she hopes to have achieved early in the New Year. The manager and staff confirmed that staff meetings are being carried out on a regular basis, but only two had been minuted since May’05. Similarly, service users confirmed that they are being invited to resident’s forums at regular intervals, but these too are not always recorded. The home has a quality assurance system in place, but the results of this years survey have not yet been published. This matter needs to be addressed as a matter of urgency. There have been improvements in the number and frequency of staff supervision sessions since the homes last inspection, although the manager conceded that only 50 of her current staff team have received them on a bimonthly basis since May’05, the rest have only had one or two in this eight month period. The manager said that two members of her senior team will be receiving supervision training on 18th December ’05 and thereafter will be able to supervise their colleagues and share this responsibility with the manager. This matter has been identified as a significant shortfall in the homes two previous inspection reports and the timescale for action will be extended for a third and final time. The Commission may consider taking enforcement action if no progress is made by 1st April 2006. Inspection of the homes fire records indicated that a suitably trained engineer has not tested the fire alarm system in the past twelve months, contrary to health and safety regulations. Furthermore, although the home has a fire risk assessment in place it has not been reviewed in the past year and up dated accordingly. Certificates of worthiness were in place as evidence that the homes portable electrical appliances and emergency lighting has been tested by suitably qualified professionals in the past twelve months, although the homes gas installations test remains overdue having last been checked in Nov’04. Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 3 X X X X 3 X STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X 1 X 1 Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1) & 17(1)(a) Requirement A record of the needs assessment undertaken by the home in respect of all prospective new service users must be kept in the home at all times. Care plans must set out in greater detail how each service users current and anticipated specialist mental ill health needs will be met (for example through positive planned interventions; rehabilitation and therapeutic programmes; structured environments; development of language and communication; adaptations and equipment; and one to one support). Care plans must be reviewed at least once every quarter and updated accordingly to reflect changing needs. A written record of these quarterly review meetings must be kept in the home at all times and made available for inspection on request. Previous timescale for action of 1st June 2005 not met. DS0000025811.V257147.R01.S.doc Timescale for action 01/01/06 2 OP7 15(1) & 17(1)(a) 01/04/06 3 OP7 15(2) 01/01/06 Mary`s Home Version 5.0 Page 26 4 OP9 13(2) 5 OP9 13(2) 6 OP9 13(2) & (4) 7 OP9 13(4) 8 OP16 13(4) 9 OP18 13(4) & 15(1) 10 OP18 13(4) (6) All medicines received by the home must always be ‘checkedin’ by suitably trained staff and a signed and dated record kept. All Controlled drugs held by the home must be correctly stored in a locked space within a locked metal cabinet; and a specialist register kept of all Controlled medicines received, administered and/or disposed of by the home. NB. The handling of any Controlled drugs in the home must always be witnessed by another suitably trained member of staff and the Controlled drugs register always counter signed by both staff involved. Protocols for the appropriate use of all ‘as required’ (PRN) medication must be drawn up in consultation with all the relevant professionals, setting out clearly under what circumstances this type of medication should be administered, for how long, and who ultimately responsible for ‘authorising’ its use. A written assessment of the risks associated with service users who have chosen to selfmedicate must be avialable for inspection on request. A record must be kept of the agreed action to be taken by both staff and service users to minimise the likelihood of certain incidents reoccurring. Care plans must contain more specific guidance for staff regarding how to deal with incidents of verbal aggression, including what might ‘trigger’ such behaviour. The use of the word restraint in the homes dealing with aggression policy must be removed as a matter of urgency DS0000025811.V257147.R01.S.doc 01/01/06 15/01/06 01/02/06 01/02/06 01/02/06 01/03/06 15/01/06 Mary`s Home Version 5.0 Page 27 11 OP27 13(6) & 19(1) 12 OP32 12(2) (3) & 18(1) 13 OP33 24(1) 14 OP36 18(2) 15 OP38 23(4)(c) (v) 13(4) & 23(4) 13(4) & 23(2)(c) 16 17 OP38 OP38 as it contravenes the homes non physical interventionalist approach to care. Previous timescale for action of 15th May 2005 not met. All new members of staff must be checked against the Protection Of Vulnerable Adults register before being allowed to commence their employment at the home. Previous timescale for action of 15th May 2005 not met. Staff meetings must be undertaken at least bi-monthly and minutes taken. Similarly service users meetings must also be recorded. The results of service surveys/questionnaires undertaken to ascertain service users/stakeholders views about the home must be published each year as part of an effective quality assurance system. All care staff working at the home must receive at least one formal supervision session with a suitably qualified senior every two months. Previous timescales for action of 15th May 2004 & 1st June 2005 not met. A suitably trained engineer must periodically test the homes fire alarm system on an annual basis. The fire risk assessment for the building must be reviewed at least once a year. The homes gas installations must be tested by a ‘suitably’ qualified professional at least once a year. Previous timescale for action of 1st June 2005 not met. 01/01/06 01/01/06 01/02/06 01/04/06 01/02/06 01/02/06 01/02/06 Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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 OP12 Good Practice Recommendations The manager should consider introducing a separate activities book to record all the social, leisure and recreational pastimes the service users choose to engage in. 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 estblished 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. 2 OP28 3 OP31 Mary`s Home DS0000025811.V257147.R01.S.doc Version 5.0 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.V257147.R01.S.doc Version 5.0 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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