Inspection on 29/05/08 for Mclaren House

This inspection was carried out on 29th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Mclaren House 14/05/07

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 28/09/2008.

CARE HOME ADULTS 18-65 Mclaren House 93 Bratt Street West Bromwich West Midlands B70 8SH Lead Inspector Martin George Key Unannounced Inspection 29th May 2008 08:45 Mclaren House DS0000004784.V362553.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.V362553.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.V362553.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.V362553.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th May 2007 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 two 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.V362553.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out by a single inspector between 08:45 and 14:25. As part of the inspection all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’ were inspected. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home through their annual quality assurance assessment (AQAA). Information from the last key inspection report and surveys from service users and staff were analysed prior to inspection and helped to formulate a plan for the visit and helped in determining a judgement about the quality of care the home provides. On the day of the inspection we spoke to the registered manager, staff and service users, undertook a tour of the premises and observed practice and this provided evidence in support of the records that were also checked on the day. What the service does well: What has improved since the last inspection? What they could do better: Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 6 The Annual Quality Assurance Assessment (AQAA) that was submitted prior to this inspection was incomplete and should be completed more fully in future. The statement of purpose needs to be completed and terms and conditions of residence need to specify fees and what is regarded as an extra cost so that service users and their families are informed of services and what the true cost of care is. The home needs to show how service users and their families are involved in devising care plans. Risk assessments/action plans need to be dated and show evidence of who devised them. The home needs to record all compliments and complaints. The adult protection procedure should include the referral process to be used in the event of an allegation of abuse. There needs to be an agreement from service users who agree not to have screens in shared rooms. Supervisions and staff meetings should meet the frequency defined in NMS. Induction should be consistent with Skills for Care. Quality Assurance (QA) systems need developing. Regulation 26 visits need to take place and be recorded. Gaps in policies need to be addressed without undue delay. Improvements in all these recording processes will help to ensure that service users are provided with consistent, safe and competent standards of care. 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. The summary of this inspection report can be made available in other formats on request. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 7 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.V362553.R01.S.doc Version 5.2 Page 8 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 Service users and their families would be better informed about the cost of the service if given clear information about fees and extras. Service user needs are met through the assessment process but information needs to be consistent with National Minimum Standards to ensure the full range of needs are covered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager informed us that there have been no new admissions since the last key inspection in May 2007. The service user guide has been completed and covers information service users might need. A copy is provided to each service user. The statement of purpose has not been revised as required at the previous two inspections and this has now been outstanding for some considerable time. The manager told us she was about halfway through the revisions, but as this has been outstanding since February 2005, we find this very disappointing as current and prospective service users and their families need to be accurately informed about how the home operates, to satisfy themselves that it can meet their needs. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 9 The statement of terms and conditions of residence are kept on service user files but they do not specify fees, which has again been highlighted in previous reports, and the list of extras are inconsistent with the list of extras given in the service user guide. Service users and their families need to know exactly what the fees cover and which services require an additional fee. The statement of terms and conditions of residence is confusing at section 3, where it appears to imply that the fees are inclusive and that there are no extras, but the manager confirmed that there were extras. This needs rectifying without undue delay. The home ensures there is a needs assessment acquired or carried out prior to admission but these would benefit from some further development to ensure they include all the elements contained in National Minimum Standard (NMS) 2.3 Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 10 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, 8 and 9 Quality in this outcome area is good Service users are supported by a team of staff that understand their needs. Care plans are consistent with the needs assessment but need further development to ensure they take account of the Mental Capacity Act so that service users right to make decisions are managed according to the Act. Service users are given choices about their day to day lives, giving them their preferred level of independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We examined the care plans of three service users and were satisfied that they were based on the needs assessment acquired pre admission. We noted that care plans are reviewed on a regular basis by the manager to ensure identified needs continue to be met. There is no clear evidence of how service users, their advocates or family are involved in the devising of care plans and we would like to see this aspect of service user involvement being developed. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 11 As noted at the last key inspection in May 2007 the practice of issuing some service users with cigarettes under supervision is still happening, but with no clear indication in the care plans of how this is assessed or any evidence of how it is consistent with the Mental Capacity Act. Accident reports are completed correctly and outcomes clearly recorded. We saw evidence of how service users are helped to develop life skills and how the home responds to service user surveys in respect of areas they wish to develop. One example of this was how the home responded to a service user who wants to develop his reading and writing skills. The service user files contain consents with regard to service users who wish to administer their own medication and for those who agree to having assistance with their medication administration. Although we saw some good risk action plans, they need to show who devised them and the date they were completed. We were also unable to identify when risk assessments/action plans were reviewed or the frequency of any reviews. We observed several staff/service user interactions that evidenced how staff help service users to make decisions, such as whether to save for a holiday or spend their money on something now. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good Service users are encouraged and supported to be as independent as they are capable of being and are given the opportunity to express and act on choice to influence day to day life at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In response to an in-house survey one service user was offered the opportunity of attending a reading and writing course at the local daycentre but found it too challenging. Staff are now helping the service user with literacy skills and hope to get him re-engaged on the course at a later date. We looked at the activities book and noted that it shows what has been done each day, who took part and whether or not they enjoyed it. Activities include board games (scrabble is particularly popular), arts and crafts, going to the pub, meals out, trips to the local safari park, Blackpool and theatre trips. We also saw evidence that service users use the local library. The manager and Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 13 staff we spoke to stated that links with the local community are good and that service users are generally integrate well with the local community. All service users, except one, have keys to their room and the front door. The service user who does not have a key needs a risk assessment completing stating reasons why he does not. Our observations of the interaction between staff and service users evidenced a respectful and responsive approach to individual needs. Menus incorporated service user preferences and food choice and involvement in preparation by service users was good. Service users we spoke to stated that they were very happy with the range and quality of the food provided. We were informed that service users are encouraged and supported in making or assisting with the making of meals. We observed a discussion with one service user about what she was going to make later that day and how she would do it. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 14 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 good Improvements to the medication procedures have helped to further safeguard service users from potential harm. Service users continue to receive appropriate support from external healthcare professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The level of support with hygiene that each service user needs is well known about by the staff team and is recorded appropriately. The records we examined evidence that personal and healthcare support is provided to service users consistent with their assessed needs. Service users we spoke to were very happy with how they were treated by staff. We are satisfied that service users feel respected and have any personal care needs managed safely. The medication procedures in the home have been updated since the last key inspection in May 2007 and is written in an easy to follow style and terminology. Our observation of the morning medication administration round Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 15 evidenced that practice is consistent with the policy and procedure. All but one of the service users are given the medication to administer themselves. Two staff always deal with the medication administration and recording and double checks are made to ensure the correct medication is given to each service user. Storage facilities for medication are consistent with regulations. None of the current service users are on controlled drugs but the home is equipped to deal with controlled drugs if required. None of the current medication used by service users needs to be kept in a medication fridge but the home should acquire one in the event that it is needed in the future. A reset thermometer will also be required. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 16 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 good Service users know their right to make complaints and expressed satisfaction with the service being provided. All complaints and compliments need to be recorded in the appropriate book. The adult protection policy should include information on dealing with allegations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The only complaint made since the last key inspection with regard to a service user has now been fully resolved as the complainant withdrew the complaint and wrote a letter of apology to the home. There are no complaints recorded in the compliments and complaints book. We asked why the complaint mentioned above was not included and were told that the complaint had been sent to the proprietor and the manager was not sure she should record it the complaints book. The home needs to record all complaints in the book irrespective to whom the complaint is originally sent to ensure there is evidence of how service users are safeguarded. Service users we spoke to were adamant that they have never had any reason at all to raise a complaint and gave us assurance they understood what a complaint was. The complaints policy would benefit by including the current address and phone/fax numbers for the Commission for Social Care Inspection (CSCI). Although the manager and staff indicated the home had received compliments from family and professionals these were not recorded in the compliments and complaints book. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 17 The adult protection policy has been updated by the manager but although it clearly identifies types of abuse it has no details about the process to use if an allegation of abuse is made. The manager assured us it was consistent with Sandwell’s 2003 adult protection policy, which the manager has checked is the most up to date version. We observed three service users carrying out financial transactions at the home and are satisfied that the system being used by the home safeguards the rights and financial interests of service users satisfactorily. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 18 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, 25, 28 and 30 Quality in this outcome area is good Service users live in a well maintained and decorated home and are allowed to personalise their bedrooms. Written agreements need to be in place to evidence that service users who share a room are happy not to have screens. Confirmation from the Environmental Health Officer (EHO) is required about the need for fly screens in the kitchen to ensure service users are protected from the risk of cross contamination. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although service users are restricted to smoking in the designated smoking area (the conservatory) we noticed a smell of cigarette smoke in the corridor leading from the front door to the kitchen/dining area. The previous key inspection in May 2007 stated that an extractor system may help but we were informed that the EHO was consulted about this and advised the home it was not necessary as the conservatory has opening windows. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 19 The bedrooms we saw are all of a good size and there is evidence that service users are encouraged to personalise their rooms. The shared rooms have no screening but the manager informed us that the service users have expressed that they do want screening and are happy to use the en-suite facility should they need an element of privacy. The home needs to have a signed and dated agreement from each service user to state they are happy not to have the screen, to evidence that service users are being fully safeguarded and that their dignity is being protected. The standard of décor throughout the home is good and well maintained. The kitchen area is clean and well ordered and all necessary checks, such as fridge and freezer temperatures and cooked food temperatures are being carried out regularly and recorded. Two top opening windows were open in the kitchen but there were no fly screens. Apparently, this was not commented on by the EHO at her recent visit but the manager was unable to locate the report of the visit, which we have asked to have forwarded onto us when it is found. We are of the opinion that fly screens will enhance the level of protection given to service users from the risk of cross contamination. The laundry area is well organised with suitable machines for the needs of the service user group. The EHO (Jayne Phillips) from Sandwell awarded the home with a gold standard for food hygiene in January 2008. The home is to be commended for this achievement. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 20 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): 32, 34, 35 and 36 Quality in this outcome area is adequate Supervisions and staff meetings need to occur at the required frequency to ensure staff are given the professional support and guidance they need to maintain consistency and competence in order to fully safeguard service users. The home needs to implement the Skills for Care induction programme and ensure employment gaps are identified on the application form before there is a need to recruit again. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA identifies that all care staff are qualified to either NVQ 2 or 3 care. The AQAA also shows that the staff compliment covers the whole age spectrum and is ethnically diverse. The team is predominantly female. One service user, when asked about the staff stated, “they are all brilliant”. Another service user referred to the manager as “the best”. Staffing records we examined showed that some staff are falling well short of the required minimum of 6 recorded supervision sessions per year. One of the seniors had periods of a year between supervision sessions. His last two supervisions were August 2007 and before that September 2006. We regard Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 21 this as a serious shortcoming and has the potential of leaving staff feeling unsupported and vulnerable, which could adversely affect the wellbeing of service users. The manager carries out all supervisions and acknowledged that supervisions have not been given the necessary priority. Staff meetings also fall well short of the required minimum of six per year. Only one staff meeting took place in 2007 and there has been no staff meeting to date this year. The minutes of the last meeting (held in December 2007) have yet to written up in the staff meeting book and are just on A4 paper which could easily be lost. The frequency of supervisions and staff meetings were made a requirement at the last key inspection and it is disappointing that they have not been given the necessary priority to ensure staff are kept fully equipped and supported in their primary role of safeguarding service users. The staff files we examined provided evidence of annual appraisals, but as supervisions are so erratic it is hard to see the link between supervision and the appraisal process. Although the home ensures that newly appointed staff undertake an induction programme the one currently in place is not consistent with the Skills for Care common induction standards. The manager is aware of the new standards and has a copy of the guidance. It is now necessary for the home to ensure it is ready to use the Skills for Care induction when they next appoint staff. We are pleased to see the home committing to a programme of training but we noted a training shortfall in that there is nothing planned around the Mental Capacity Act. This needs to be arranged without undue delay to ensure staff are equipped with the necessary skills and knowledge to assist in the development of care plans. There has been no need to recruit staff since the last inspection but the home needs to ensure that when they do next recruit they acquire details of any gaps in employment to fully safeguard service users. The home needs to contact the Criminal Records Bureau (CRB) to check on the latest guidance regarding how long CRB checks should be retained on staff files. We would like to see the home implement a register listing CRB disclosure numbers and when received by the home. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 22 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, 41 and 42 Quality in this outcome area is adequate Although staff stated they are well supported by the manager there is little evidence of this through supervision records and staff meeting minutes, providing minimal evidence of how staff are supported to meet service users needs. Quality Assurance (QA) systems need significant development to show how views acquired are influencing practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager holds the Registered Managers Award (RMA) and NVQ 4 (Care). The acting deputy holds the NVQ 3 (Care). A quality assurance system has been introduced since the last key inspection but it is very much in its’ infancy. Views of service users have been sought Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 23 through in-house questionnaires but there is no evidence of analysis for how the views have influenced practice. The manager needs to acquire a recognised QA system and implement it as soon as possible to show how the delivery of services is resulting in improvements to service users. Fire drills and evacuations are occurring as required and are recorded, with length of time an evacuation takes. The home needs to acquire the relevant guide for care homes to ensure they are carrying out annual fire audits that are consistent with the Regulatory Reform (Fire Safety) Order 2005. Insurance certificates are up to date and are on show in the main entrance lobby. We saw evidence that water temperatures are regularly monitored and that Legionella checks are carried out. This provides evidence of how service users are safeguarded in this aspect of their care. The Care of Substances Hazardous to Health (COSHH) records are well maintained. The file would benefit from having an index to make it easier to find the relevant data sheet in an emergency. Although all the staff need refresher training in infection control and moving and handling the relevant training has been planned for the near future. Infection control training is happening in June 2008. The previous requirement that Regulation 26 visits be completed and copies of the reports made available for inspection by CSCI inspectors remains outstanding. The manager informed us that the proprietor does visit the home on a regular basis but there is no evidence of her findings following visits. The policy and practice with regard to service user finances is good and satisfactorily safeguards their rights and interests. The nutrition and menu planning policy has recently been updated. There are a number of policy shortfalls that need to be rectified without undue delay. These include bullying, first aid, disposal of clinical waste, individual planning and review, sexuality and relationships, smoking and use of alcohol and substances by service users, staff and visitors. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 24 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 3 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x LIFESTYLES Standard No Score 11 x 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 3 x 3 x 2 x 2 2 x Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The homes statement of purpose needs to include all the information required under the Care Home Regulations 2001 to ensure prospective residents and their families are given all necessary information. Statements of terms and conditions or contracts need to contain all information listed in the Care Home Regulations 2001 and be included in the service user guide to ensure service users are given all necessary information. The home needs to 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. The service users sharing a room need to sign an agreement to confirm they do not wish to have screening. 2. YA5 3. YA20 4. YA25 Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 26 5. YA28 6. 7. 8. YA30 YA6 YA34 9. 10. 11. YA36 YA39 YA41 The home should make sure it is complying 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. Provide CSCI with a copy of the most recent EHO report to confirm whether the issue of fly screens in the kitchen was addressed. Ensure care plans comply with the Mental Capacity Act to ensure people’s rights are protected. The home needs to 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. Supervision frequency should be in accordance with NMS to ensure staff are supported in maintaining competence to continue safeguarding service users. The manager should make improvements to quality monitoring systems to show how views acquired are influencing service delivery. The registered provider must complete Regulation 26 visits in order to fulfil her legal obligations. Mclaren House DS0000004784.V362553.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V362553.R01.S.doc Version 5.2 Page 28 - 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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