Inspection on 16/01/06 for Mclaren House

This inspection was carried out on 16th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 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 14/05/07

Mclaren House 05/07/06

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 Mr Mike Kirton Unannounced Inspection 16th January 2006 11:00 Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 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.V278337.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V278337.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mclaren House Address 93 Bratt Street West Bromwich West Midlands B70 8SH 0121 500 5430 0121 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 Mrs Paulette Rowena Shirley Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30th August 2005 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.V278337.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours and included interviews with the acting manager, and informal discussions with 2 service users, and the staff on duty. Additionally 2 service users files were examined along with records relating to health and safety. All outstanding requirements were monitored. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 6 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.V278337.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 30th August 2005. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The standard of care planning, review, and assessment is very poor. Whilst some elements of this are outside the managers control more could have been done to access advocacy services. Admission procedures (see previous report dated 30th August 2005) should also have been followed better. This does not necessarily reflect badly on the personal care provided and excellent feedback was received. EVIDENCE: The care plans were examined for 2 service users. Neither of these had been reviewed or updated. This should be done at least every 6 months or when needs change. The plan itself did not cover all the needs identified in their assessment, which had been updated, and actions were being carried out i.e. fluid intake chart without this being identified as a need. This itself was not done accurately or consistently. No nutritional assessment had been completed and risk assessments for violence and aggression had not been completed, and did not address the issues raised in their needs assessment. There was no guidance for staff on early warning signs or relapse prevention plans regarding mental health or Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 9 aggression. It was also identified that 1 service user was not in receipt of all benefits they may have been entitled to. The last Care Programme Approach (CPA) care plan was dated 18 months ago and had not been updated or review held for 1 service user. There were some problems relating to their transfer between authorities and allocation of a social worker. No alternative assistance had been sought such as Citizens Advice, solicitor or an external advocate. All residents apart from the individual records examined, had a daily living programme. Feedback received from service users was very good. One person described how good the care had been and described the home ‘as my backbone’ and enabled them to remain well and increase their independence. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 30th August 2005. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The homes systems for monitoring health needs are satisfactory and ensure that appropriate referrals are made. Medication procedures are adequate and safe administration procedures are followed. Proactive steps are being also being taken to promote healthy eating and lifestyles. EVIDENCE: The 2 service users files examined contained a health tracker sheet, which monitored all referrals and visits to specialist professionals. This however was not being completed consistently and information was recorded on different systems. All appointments were entered in the homes diary and staff support was provided if needed to accompany them. The home has introduced a healthy eating plan and has started to make fruit and vegetables more available, and is offering a healthy choice on the main menu. More activities are being introduced such as short walks and shopping trips. Weight is also monitored on a monthly basis. All personal care was provided in private. Feedback from service users confirmed that appropriate health care was being provided i.e. dentist and chiropody. Additionally they were able to plan their own daily routines and lifestyle. The homes rules were clearly displayed on notice boards and in their statement of purpose. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 12 Copies were seen for all medication received by the home. This was checked and recorded in the receipt book. Similarly the pharmacist signed for any returns. A procedure has been introduced to enable those who are able to put their own tablets into a weekly medic-pack. All others are given straight from the prescribed container. Guidance was provided for medication only to be given when needed (PRN). Blood test results, blood pressure, and depot injections were monitored. The home uses their own record sheets however all containers are labelled when opened. Staff have all undergone recent training and copies of their signatures were available. Pharmacy inspections were also carried out on a regular basis. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 30th August 2005. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The planned improvements to the home are being carried out to a high standard and once competed will provide a good environment which is safe and comfortable. EVIDENCE: A tour of the building and grounds took place. The paved front drive and rear gardens were well maintained and finished to a good standard. Some brickwork however looked as if it was loose and required further examination. The premises are now going through a planned refurbishment and decoration. The 2 double bedrooms have been provided with en-suit shower and toilet facilities. The bathroom and toilet on the 1st floor has been re-tiled and a new floor fitted, and plans to turn the 2 ground floor toilets into a toilet with shower have nearly finished. Work should begin on the new kitchen with 6 weeks and new carpets, ceilings, and re-decoration will continue throughout the home. The manager must ensure that all residents are continually kept informed about any planned work at the home and disruption kept to a minimum. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 15 The laundry facilities, although accessed through the kitchen, are considered by the manager to be appropriate for the current needs of the service users. A procedure is in place for the safe handling of washing and all service users clothing and bedding is done separately. This is carried through the kitchen in sealed plastic bags. The room itself was tidy and kept clean. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 30th August 2005. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Satisfactory procedures are in place to ensure the health and safety of service users is protected. The manager has yet to implement a quality assurance system or taken action to meet outstanding requirements, which has exceeded agreed timescales for completion. EVIDENCE: The acting manager has undergone an interview with the Commission however further information is still required before they can be registered. They must also take action to ensure all outstanding requirements are met within the agreed timescale. A quality assurance system has not yet been implemented. Feedback should be sought from service users along with the views of staff, visitors and other people who have contact with the home. This needs to be collated and an action plan implemented to improve on existing standards. Further standards such as staff turn over and accidents in the home should also be included. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 18 The home has been fitted with a modern fire alarm, which alerts staff to a particular zone where the fire might be located. An updated fire risk assessment is needed following the fire inspection in April 2005. All staff have undergone training however not everyone has received 2 fire drills over the last 12 months. All equipment has been serviced as required and the alarms tested weekly. The manager also carries out health and safety risk assessments every month. The fridge, freezer, cooked food, and water temperatures were being recorded and monitored. Servicing of the gas, electrics, and portable electrical appliances was been undertaken. Risk assessments have been completed for the building and activities carried out both inside and outside the home. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 1 X X 2 X Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 20 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 4,6 Requirement The homes Statement of Purpose and service user guide needs to include all the information required under the minimum standards. This is an outstanding requirement from 9th February 2005. Comprehensive assessments must be completed for all perspective service users before admission. Assessment information including a current Care Programme Approach (CPA) care plan and assessment must be received before admission. This is an outstanding requirement from 30th August 2005. The home must be able to confirm in writing that they are able to meet service users needs before admission. This is an outstanding requirement from 30th August 2005. The home must update its admission procedure in line with current practices and DS0000004784.V278337.R01.S.doc Timescale for action 01/04/06 2. YA2 14,15 01/04/06 3. YA3 14,15 01/04/06 4. YA4 14 01/04/06 Mclaren House Version 5.1 Page 21 5. YA5 6. YA6 7. YA9 8. YA14 9. YA17 minimum standards. This is an outstanding requirement from 30th August 2005. 17 Statements of terms and conditions or contracts must meet the minimum standards and be completed with all service users. The use of advocates should be used if necessary. This is an outstanding requirement from 9th February 2005. 14,15 Care plans must be implemented upon admission clearly stating how all assessed needs will be met. Long and short-term goals must be identified and monitored. This is an outstanding requirement from 9th February 2005. 12,13,14,15 Risk assessments must be developed, completed with service users upon admission and reviewed as needed. Particular attention must be given to issues of violence and aggression. This is an outstanding requirement from 9th February 2005. 12(3), Service users must have an 16(2)(m) annual 7-day holiday included as part of the basic contract price. This is an outstanding requirement from 9th February 2005. 12,13,14,15 Service users nutritional needs are assessed and any action is recorded in their care plan. This is an outstanding requirement from 9th February 2005. 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 22 10. YA22 22 11. YA23 12,37 12. YA24 16,17 13. YA34 19 14. YA35 19 15. YA36 19 16. YA39 17 The complaints policy must be updated and state that the CSCI can be contacted at any time of the process. This is an outstanding requirement from 9th February 2005. The homes whistle blowing and adult protection procedures must be updated. Staff must sign to state they have read and understood the procedures. This is an outstanding requirement from 9th February 2005. The home must implement a planned maintenance and renewal programme covering the fabric and decoration of the property including dates for further building work to be undertaken. A copy must be submitted to the Commission. This is an outstanding requirement from 9th February 2005. All staff must have a police record check (CRB & POVA). This is an outstanding requirement from 30th August 2005. All needs identified through individual training plans must be met. Copies of qualifications must be kept on file. This is an outstanding requirement from 30th August 2005. Supervision must be provided at least 6 times a year with an annual appraisal. This is an outstanding requirement from 30th August 2005. The furniture and fittings in bedrooms must meet the DS0000004784.V278337.R01.S.doc 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 Mclaren House Version 5.1 Page 23 17. YA39 17,24,36 18. YA40 12,17,18 19. YA42 9,10,12,13 minimum Standards unless not required by the service users or there is a health and safety issue. This is an outstanding requirement from 9th February 2005. Quality assurance procedures need to be implemented and systems used to obtain and record the opinions of the service users, friends, relatives, visitors and others. This is an outstanding requirement from 9th February 2005. All policies as listed in Appendix 2 of the standards are implemented and reviewed. These should be signed and dated by the manager and by all staff once they have read and understood them. This is an outstanding requirement from 9th February 2005. The acting manager must submit the outstanding information required by the Commission before they can be registered. Decanted cleaning materials must be labelled in line with legal requirements. The loose brickwork on the rear first floor building must be examined. The fire risk assessment must be updated as required by the last fire officer’s report. 01/04/06 01/04/06 23/01/06 Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 24 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 YA19 Good Practice Recommendations The home should make sure the method for tracking health care needs is used accurately and consistently. Mclaren House DS0000004784.V278337.R01.S.doc Version 5.1 Page 25 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: 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. 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