Inspection on 14/05/07 for Mclaren House

This inspection was carried out on 14th May 2007.

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 no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mclaren House 29/05/08

Mclaren House 05/07/06

Mclaren House 16/01/06

Mclaren House 30/08/05

Mclaren House 09/02/05

Mclaren House 15/09/04

Mclaren House 18/03/04

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

CARE HOME ADULTS 18-65 Mclaren House 93 Bratt Street West Bromwich West Midlands B70 8SH Lead Inspector Mrs Lesley Webb Unannounced Inspection 14th May 2007 09:15 Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mclaren House Address 93 Bratt Street West Bromwich West Midlands B70 8SH 0121 500 5430 F/P0121 500 5430 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) Mrs Paulette Shirley June Phillips Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection July 2006. Brief Description of the Service: McLaren House is registered to provide residential care for 9 people aged between 18 and 65 who are experiencing mental ill health. The aim of the home is to provide a rehabilitation service to enable its users to return to living independently in the community. There are however no set limits and this may be over a long period of time. The home is a three storey mid-terraced property situated close to West Bromwich town centre with easy access to all local amenities and transport networks. There is parking space for 2 cars at the front of the property and gardens at the rear. Accommodation is provided over three floors. On the ground floor there is an office, staff toilet, one single bedroom, lounge, dining room, conservatory (smoking room), kitchen, laundry and toilet with a shower. On the first floor there are four single bedrooms and a bathroom with toilet. The second floor has two double bedrooms both with en-suite toilet and shower facilities. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this visit over one day with the home being given no prior notice. During the visit time was spent talking to people who live at the home, examining records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen were male and female, from different cultural backgrounds and have differing support needs. Eight survey forms were completed by people who live at the home (one with assistance from a member of staff). Information from these and from documentation supplied by the home prior to the inspection was also used when forming judgements on standards of service provided. Fees charged for people currently living at the home range from £550.00 to £675.00. Additional charges are made for toiletries, magazines, papers, trips out and holidays. A fee of £763.00 will be charged for any new person wishing to move to the home. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well: All eight people who live at the home completed questionnaires regarding their views and opinions on services provided by the home. Of these six state they were asked if they wanted to move into the home and that they were given enough information about the home so they could decide if it was the right place for them and two that they were not. Additional comments made include ‘I was treated very kindly when I came to this home’ and ‘I visited this home and I liked so I agreed to move into this home’ The home maintains detailed review records for each person. All those sampled gave thorough and comprehensive information relating to the care and support people living at the home receive. Of the eight service user questionnaires that were completed six state they always make decisions about what they do each day, one sometimes and one never. One additional comment relating to decisions was recorded, ‘every morning after breakfast I speak to the staff about my plans for the day. The staff are very helpful and very encouraging, every day is brilliantly planned’. People who live at this home are able to make choices about their life style, and supported to develop their life skills. As one person who lives at the home Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 6 explained, “we go different days to do our bit of shopping, then we cook what we have brought. Buy pork chops and steak, make cheese and potato pie, corn beef hash”. Families and friends are welcomed into the home, and there is no limit on the times for visiting. One person who lives at the home informed the inspector, “My niece comes and does my hair for me, my friend comes for a cup of tea and biscuit”. Menus supplied to the inspection team prior to the visit demonstrate choices of meals including meat, fish, vegetables and pasta, that dietary needs are catered for and that facilities are available to make drinks and snacks. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Of the eight service user questionnaires that were returned to CSCI seven state staff always treat them well and that staff always listen and act on what they say and one sometimes this occurs. Additional recorded comments include ‘The time I have lived here I have always been treated fairly and with respect’ and ‘From time to time the carers speak to us about the care we receive and ask us if there any issues we would wish to discuss’. What has improved since the last inspection? The manager confirmed that work has been completed to improve care plans so that they detail how care is to be delivered and what actions to be taken when circumstances change ensuring peoples needs are met. The complaints policy has been reviewed and now includes the name of the Commission for Social Care Inspection. Of the eight service user questionnaires completed all state they know who to speak to if not happy, with additional comments made including, ‘I am aware of the fact that if I have any complaints I have the right to speak to staff’ and ‘I know how to make a complaint but I have never had to made a complaint in all the time I have lived here’. Since the last inspection all communal areas have been redecorated and new carpet laid. In addition to this new chairs have been supplied in the lounge. The registered manger explained that new curtains were due to be fitted that would complete the refurbishment process, providing a comfortable place for people to live. Information supplied by the home prior to the inspection states that 85 of care staff hold a national vocational qualification, and that some staff have undertaken adult abuse and protection, medication and health and safety training. The registered manager stated that other staff have recently attended mental health training and were awaiting certificates. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 7 Improvements to recruitment and selection practices have occurred. All files sampled contained an application form and suitable written references, it was also pleasing to see that checks such as the PoVAfirst and Criminal Record Bureau disclosures were in place ensuring people living at the home are protected from harm. What they could do better: The homes statement of purpose, service user guide and contracts of residency need to include all the information required under the Care Home Regulations 2001 to ensure peoples rights are protected. Care plans and risk assessments need to be implemented for all identified needs in order that the risk of needs not being met is reduced. Behaviour management plans; protocols and procedures must be reviewed to ensure they comply with relevant legislation and good practice guidelines in order that people’s rights are protected. A written policy must be implemented for the administration of ‘as required’ medication to ensure people living at the home are protected by its systems and management of medication. The homes adult protection, aggression and restraint policies must be updated to ensure they comply with relevant legislation and protect people who live at the home from risk of injury or harm. An extraction system must be provided in the conservatory that ensures the health of non-smokers is not compromised. To ensure sufficient numbers of staff receive training in areas such as challenging behaviour, mental health, moving and handling and infection control to ensure staff are suitably qualified to support people living at the home. Improvements to quality monitoring systems must take place so people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. The registered provider must complete Regulation 26 visits in order to fulfil her legal obligations and notifications in line with Regulation 37 of the Care Home Regulations 2001 must be completed in order that people living at the home are safeguarded by the homes practices. Please contact the provider for advice of actions taken in response to this Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have up to date information about the service they need to make an informed choice. All service users can be assured that their individual needs will be assessed. Written contract or statement of conditions does not inform service users of all their conditions of residency EVIDENCE: A previous requirement to ensure the statement of purpose and service user guide includes all information as required by regulation remains unmet. Examination of these documents found that they would not inform people considering using the service about fees charged, what fees cover and what is excluded. All eight people who live at the home completed questionnaires regarding their views and opinions on services provided by the home. Of these six state they were asked if they wanted to move into the home and that they were given enough information about the home so they could decide if it was the right place for them and two that they were not. Additional comments made include ‘I was treated very kindly when I came to this home’ and ‘I visited this home and I liked so I agreed to move into this home’. There have been no new admissions to the home in the last 12 months, however the registered Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 11 manager states that if this should occur comprehensive assessments would be completed for all perspective service users and that admission procedures would be in line with current practices and minimum standards. As at the previous inspection files sampled contained a contract of terms and conditions of residency, signed by residents and the manager of the home. These still do not detail the fees charged and what people living at the home are expected to pay for. For example people living at the home are not given a seven-day holiday as part of their basic contract price. This should be indicated in the contract. If people living at the home are not provided with a contract that informs them of what service they can expect, their legal rights are not protected. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: As at the previous inspection all three files sampled contained an individual plan of care. The manager confirmed that work has been completed to improve plans so that they detail how care is to be delivered and what actions to be taken when circumstances change (meeting a previous requirement). When examining the contents of individual plans of care the inspector found that all three centred on mental and physical health needs, but that in some instances other documentation on file indicates other needs that do not have plans of care in place. For example the review records for one person state that they are choosing healthier eating options to attempt to lose weight, but no support plan is currently in place for this. Another person’s records state that they sometimes refuse medical intervention, but again no support plan is Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 13 in place for this. It was also noted that some people who live at the home have restrictions in place as part of their agreed care management (for example being given cigarettes only under supervision at specified times). The inspector informed the registered manager that care plans and risk assessments must be completed in these instances and that the home must be able to demonstrate that its actions comply with the Mental Capacity Act. The registered manger was also instructed to ensure that behaviour management plans; protocols and procedures are reviewed to ensure they comply with relevant legislation and good practice guidelines. Care plans must be introduced for any identified need in order that people living at the home are not placed at risk of not having all their needs met. The inspector congratulated the registered manager on the detailed review records maintained for each person. All those sampled gave thorough and comprehensive information relating to the care and support people living at the home receive. Of the eight service user questionnaires that were completed six state they always make decisions about what they do each day, one sometimes and one never. One additional comment relating to decisions was recorded, ‘every morning after breakfast I speak to the staff about my plans for the day. The staff are very helpful and very encouraging, every day is brilliantly planned’. There have been two residents meetings since the last inspection. Topics discussed include of attitudes, programmes, behaviour, hygiene, and cleanliness. It is recommended that records evidence action taken to address issues raised within meetings and that the frequency of meetings increases to further support people living at the home to be involved in decision making relevant to their care. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at this home are able to make choices about their life style, and supported to develop their life skills. Generally social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: As at the previous inspection evidence indicates people living at the home are encouraged to be as independent as they can be, with structured programmes in place for everyone where they are supported to develop social, daily living and independence skills. As one person who lives at the home explained, “we go different days to do our bit of shopping, then we cook what we have brought. Buy pork chops and steak, make cheese and potato pie, corn beef hash”. This was reinforced in the eight service user questionnaires that were completed, seven of which state they can do what they wish during the day and evening and eight that state they can do what they wish of a weekend. A holiday is not provided as part of the contractual agreement in place with Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 15 funding authorities. The registered manager explained that residents fund their own holidays and that the home pays for staff accommodation, provisions and wages. People that live at the home confirmed that this year they are arranging to visit the Isle of Wight. It is recommended that the home improve the amount of social activities that people living at the home can participate in. The residents activity book was viewed and found that since the last inspection no activities were recorded for August or September, three were undertaken in October, six in November, one in December, none in January, one February, none in March and one in April. Improvements in this area will ensure people living at the home lead full and active lives based on their needs and capabilities. Families and friends are welcomed into the home, and there is no limit on the times for visiting. One person who lives at the home informed the inspector, “My niece comes and does my hair for me, my friend comes for a cup of tea and biscuit”. All service users have the opportunity to receive visitors in private should they wish to do so. Daily routines are generally flexible to suit the needs of people living at the home however there must be some structure as it is part of the recovery programme for the residents. In addition to this staff sit down with individuals to help them plan for their week ahead as they are encouraged to do as much for themselves as possible in the kitchen. This includes meal planning, preparing the shopping lists and cooking the food. Menus supplied to the inspection team prior to the visit demonstrate choices of meals including meat, fish, vegetables and pasta, that dietary needs are catered for and that facilities are available to make drinks and snacks. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Improvements to some medication practices within the home will ensure people are safeguarded by the homes practices and systems. EVIDENCE: As at the previous inspection evidence indicates that people living at this home have access to a range of specialist community services should they require them, these include the mental health teams and the dentist. All but one of the people living at this home administers their own medication with support from staff. As one person explained, “under supervision to reduce danger”. Records are kept of all medicines received, administered and leaving the home to ensure that there is no mishandling of medication. Information supplied to CSCI before the visit states that ten staff are responsible for administering medication. When discussing medication training Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 17 the registered manager confirmed that competency assessments are not completed for staff that undertakes this responsibility. In the main it appears medication systems appear adequate however it was noted that a prescribed cream for one person has ran out four days before the next stock was due (the registered manager stated the GP will not supply more), a written policy is not in place for the administration of ‘as required’ medication, a prescribed cream was not dated when opened and a record of sock for Diazepam is not maintained. It is recommended that the home obtain CSCI guidance ‘Training care workers to safely administer medication in care homes’ ‘Medication administration records in care homes’ and ‘The administration of medication in care homes’ to ensure its systems comply with relevant legislation and good practice guidelines and that people living at the home are protected by its systems and management of medication. During the inspection the registered manager explained that the home is currently in the process of changing its supplying pharmacist. It is hoped this will improve systems. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at this home are able to express their concerns, and have access to a robust, effective complaints procedure. Protection policies and procedures within the home need to be reviewed in order to offer comprehensive protection from abuse, neglect or self-harm. EVIDENCE: As at the previous inspection the home has received no complaints. People living at the home were quite clear about whom they would talk to if they were unhappy. For example one person explained, “The staff are brilliant, very caring, make sure things work, give support. Never had reason to complain, we talk about complaints”. The complaints policy has been reviewed and now includes the name of the Commission for Social Care Inspection. Of the eight service user questionnaires completed all state they know who to speak to if not happy, with additional comments made including, ‘I am aware of the fact that if I have any complaints I have the right to speak to staff’ and ‘I know how to make a complaint but I have never had to made a complaint in all the time I have lived here’. The Protection of Vulnerable Adults Policy still requires reviewing to include National and Local authority guidance, so that staff can be clear of their responsibilities in reporting suspected abuse. The home has a policy for aggression, restraint and abuse that also requires reviewing as it currently does not include training that staff must undertake if the need to restrain Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 19 someone should occur and also contains information that conflicts with local authority guidelines in relation to adult protection. If implemented, the policy in its current form has the potential to place both people who live at the home and staff at risk of injury or harm. Information supplied to CSCI prior to the inspection by the home states that seven of the eight people living at the home maintain and manage own financial affairs with support. The records and finances of three people were examined and found to be accurate. It is recommended that receipts are numbered to correspond with recordings on personal allowance sheets for ease when auditing and that the home take action to ensure it does not hold monies above the amount that it is insured for to ensure practices offer further protection. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 to 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour of the premises was undertaken. Since the last inspection all communal areas have been redecorated and new carpet laid. In addition to this new chairs have been supplied in the lounge. The registered manger explained that new curtains were due to be fitted that would complete the refurbishment process. Eight service user questionnaires were completed prior to the inspection, seven of which state the home is always fresh and clean and one sometimes. An additional comment was made, ‘The staff are very hygiene conscious and there is a domestic on duty every day’. Throughout the inspection many of the people who live at the home were seen undertaking domestic duties, appearing to enjoy these events. For example one person Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 21 was seen cleaning their bedroom, explained that they do this every morning. All of the bedrooms that the inspector was invited to view appear individually decorated. The home has two double rooms both of which have en-suite facilities. One of the double rooms has one person residing in it, with the registered manager stating this has been the case for at least two years. No screening was in place within the jointly occupied room. This is recommended to ensure peoples privacy and dignity is not compromised. The home has a conservatory that is the designated smoking area. This was discussed with the registered manager, who was instructed to take action to ensure systems comply with legislation that is due to come into effect. There is currently no extraction system in the conservatory with windows left open to expel smoke. This is not adequate as throughout the inspection the smell of cigarettes was apparent in the dining room that joins the conservatory. Action must be taken to address this to ensure the health of non-smokers is not compromised. The kitchen was seen to be well stocked and clean. It was noted that there are no fly screens at any of the windows or doors despite these being open. The registered manager explained that she thought the electric fly exterminator was sufficient. It was also noted that none of the food items in the fridge were labelled with the date of opening. The home was instructed to contact the local environmental health department regarding these issues and to take action on any advice given to ensure people living at the home are protected from risk of infection. The homes laundry was viewed and found to be appropriate. The registered manager was instructed to reinforce to staff the need to store mops using the provided facility to ensure good infection control practices are maintained. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements are needed to ensure suitable numbers of staff are trained in sufficient numbers and receive supervision to support the people living at the home. EVIDENCE: Of the eight service user questionnaires that were returned to CSCI seven state staff always treat them well and that staff always listen and act on what they say and one sometimes this occurs. Additional recorded comments include ‘The time I have lived here I have always been treated fairly and with respect’ and ‘From time to time the carers speak to us about the care we receive and ask us if there any issues we would wish to discuss’. Information supplied by the home prior to the inspection states that 85 of care staff hold a national vocational qualification, and that some staff have undertaken adult abuse and protection, medication and health and safety training. It also details future training as mental health awareness, food hygiene and first aid. Of the four staff files sampled none contained certificates for mental health, two NVQ level 2, one challenging behaviours and Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 23 two adult abuse. The registered manager stated that other staff have recently attended mental health training and were awaiting certificates. She could not produce names or numbers who undertook this training. The inspector explained that the home must ensure sufficient numbers of staff receive training in areas such as challenging behaviour and mental health to ensure people who live at the home receive the required support to meet their needs. Four staff files were viewed in order to see how much progress the home is making in improving its recruitment and selection practices. Of those files seen all of them contained an application form and suitable written references, it was also pleasing to see that checks such as the PoVAfirst and Criminal Record Bureau disclosures were in place ensuring people living at the home are protected from harm. It is recommended that the home review its application form, as this currently does not ask for details of full employment history. This would offer further protection to people living at the home. Of the four staff files sampled non-contained evidence that staff receive regular, formal supervision. For example none contained evidence that staff have received supervision this year and only two that they received one session since the last inspection in July 2006. Three staff meetings have taken place since the last inspection. As at the previous inspection the acting manager was informed that both of these should occur more frequently in order to inform and support staff. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Improvements to quality monitoring systems should take place to ensure people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. EVIDENCE: June Philips is the registered manager of Mclaren House. She is qualified and competent to run the home. She has completed her NVQ level 4 and her Registered Managers Award. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 25 None of the three requirements identified in the previous inspection relating to quality assurance have been met. The home is still required to implement quality assurance procedures and systems, including obtaining and recording the opinions of service users, friends, relatives and visitors. The registered manager stated that she thought the registered provider for the organisation had recently received a system but that this is yet to be implemented. She also explained that at present the only views that are obtained are those of the residents, in the form of questionnaires (these are given out periodically). Inspection of these found that they had been completed September 2006 asking for views on the complaints procedure, staff, cleanliness of home, meals, changes to menu and activities. Additional comments recorded include ‘bacon hocks, pies and chips’ ‘new carpet in bedroom and window fixed’ ‘less fried food and more Caribbean’. The registered manager confirmed that an analysis of findings has not taken place but that action had been taken to address the comments. The inspector viewed the quality assurance policy dated January 2003 which states management review meeting are held every three months, that there is an appointed quality manager and internal quality auditor and that internal audits will take place for staff and customer. No evidence of this occurring could be found. No action has been taken by the registered provider to complete visits in line with Regulation 26 of the Care Home Regulations 2001. The registered manager stated that the registered provider visits the home on a weekly basis and telephones regularly but that reports are not completed. Also policies and procedures still require reviewing, signing and dating by the manager. Improvements to quality monitoring systems should take place to ensure people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. The inspector asked to view the homes Regulation 37 notifications. The registered manager said that none have been completed. This was discussed at length due to other evidence indicating these should have been completed. The inspector stressed to the registered manager her legal responsibilities to complete these notifications and how they offer further safeguards to people living at the home. Information supplied by the home prior to the inspection states that the fire officer visited on the 02/04/07, fire equipment was checked December 2006, the most recent fire drill took place 24/04/07, the fire alarms were tested 24/04/07, the environmental health officer visited 15/06/06, the central heating system was checked 27/04/07, a Legionella check was completed March 2007, an electrical wiring certificate was issued 06/04/07 and emergency lighting checked on 06/04/07. A random sampling of records during the inspection confirmed this information to be accurate. Action has been taken to address requirements relating to safety. For example decanted cleaning materials are now appropriately labelled, loose brickwork has been examined and the fire risk assessment has been updated. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 3 2 2 X Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 4,5 Timescale for action The homes statement of purpose 01/08/07 and service user guide need to include all the information required under the Care Home Regulations 2001 to ensure peoples rights are protected. This is an outstanding requirement from 9th February 2005. Statements of terms and 01/08/07 conditions or contracts must contain all information as listed in the Care Home Regulations 2001 in order that people’s rights are protected. This is an outstanding requirement from 9th February 2005. To ensure care plans are 01/07/07 implemented for all identified needs in order that the risk of needs not being met is reduced. To ensure care plans are 01/07/07 implemented for any restrictions on choice and that they comply with the Mental Capacity Act to ensure peoples rights are protected. To ensure that behaviour 01/07/07 management plans; protocols and procedures are reviewed to DS0000004784.V334149.R01.S.doc Version 5.2 Page 28 Requirement 2 YA5 5(1) 3 YA6 15 4 YA6 15 5 YA6 15 Mclaren House 6 YA9 13(4) 7 YA20 13(2) 8 YA23 13(6) 9 YA23 13(6) 10 YA28 23(2)(p) 11 YA32 18(1)(a) 12 YA36 18(2)(a) ensure they comply with relevant legislation and good practice guidelines in order that people’s rights are protected. Assessments of risk must be completed for all identified needs to reduce and manage the risk of harm to people. A written policy must be implemented for the administration of ‘as required’ medication to ensure people living at the home are protected by its systems and management of medication The homes vulnerable adults policy must be updated to include information from National and Local authority and give clear guidance to staff of their responsibilities in reporting suspected abuse, offering greater protection to people. This is an outstanding requirement since July 2006. To review and amend the aggression, restraint and abuse policy to ensure it complies with relevant legislation and protects people who live at the home and staff from risk of injury or harm. To provide an extraction system in the conservatory that ensures the health of non-smokers is not compromised. To ensure sufficient numbers of staff receive training in areas such as challenging behaviour and mental health to ensure people who live at the home receive the required support to meet their needs That staff received regular support (e.g. staff meetings and supervision) in order that they can meet the needs of people living at the home. 01/07/07 01/08/07 01/08/07 01/08/07 01/09/07 01/08/07 01/09/07 Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 29 13 YA39 24 14 YA41 26 15 YA41 37 16 YA42 13(3) 17 YA42 13(5) To make improvements to quality monitoring systems so people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. This is an outstanding requirement from February 2005. The registered provider must complete Regulation 26 visits in order to fulfil her legal obligations. This is an outstanding requirement from July 2006. To ensure notifications in line with Regulation 37 of the Care Home Regulations 2001 are completed in order that people living at the home are safeguarded by the homes practices. Sufficient numbers of staff must receive training in infection control in order that people are not placed at risk of injury or harm Sufficient numbers of staff must receive training in moving and handling in order that people are not placed at risk of injury or harm. 01/09/07 01/07/07 15/05/07 01/08/07 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations That records evidence action taken to address issues raised within residents meetings and that the frequency of meetings increases to further support people living at the home to be involved in decision making relevant to their DS0000004784.V334149.R01.S.doc Version 5.2 Page 30 Mclaren House 2 YA14 3 4 5 YA17 YA20 YA20 6 YA23 7 8 YA25 YA28 9 YA30 10 YA32 11 YA34 care. That the home improve the amount of social activities that people living at the home can participate in to ensure people living at the home lead full and active lives based on their needs and capabilities. That the nutritional needs of people are assessed using a recognised tool in order that holistic health management is promoted. That the home obtains further supplies of prescribed cream for a named person in order that they have sufficient to last each month and to meet their needs. That the home obtain CSCI guidance – ‘Training care workers to safely administer medication in care homes’ ‘Medication administration records in care homes’ and ‘The administration of medication in care homes’ to ensure its systems comply with relevant legislation and good practice guidelines. That receipts are numbered to correspond with recordings on personal allowance sheets for ease when auditing and that the home take action to ensure it does not hold monies above the amount that it is insured for to ensure practices offer further protection to those living there. That screening is provided within the jointly occupied room to ensure peoples privacy and dignity is not compromised That the home takes action to ensure compliance with Regulation 2 of the Smoke Free (Premises and Enforcements) Regulations 2006, to ensure the health of people living at the home is not compromised. To contact the local environmental health department regarding labelling of food, fly screens and food analysis and to take action on any advice given to ensure people living at the home are protected from risk of infection. It is recommended that the manager produces a training matrix that clearly demonstrates what training staff have received and when refresher training is due in order that effective monitoring can take place. That the home reviews its application form, as this currently does not ask for details of full employment history. This would offer further protection to people living at the home. Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Mclaren House DS0000004784.V334149.R01.S.doc Version 5.2 Page 32 - 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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