Inspection on 06/11/07 for McNulty Court

This inspection was carried out on 6th November 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

McNulty Court 20/12/06

McNulty Court 02/11/05

McNulty Court 09/08/05

McNulty Court 27/10/04

McNulty Court 29/04/04

McNulty Court 17/09/03

McNulty Court 25/04/03

McNulty Court 14/08/02

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

CARE HOME ADULTS 18-65 McNulty Court 16 McNulty Court Dudley Northumberland NE23 7HX Lead Inspector Alan Baxter Unannounced Inspection 6th November 2007 09:30 McNulty Court DS0000000377.V352864.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 McNulty Court DS0000000377.V352864.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. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service McNulty Court Address 16 McNulty Court Dudley Northumberland NE23 7HX 0191 2500946 0191 2500946 vivienne.jeffrey@nhs.net 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) Northumberland, Tyne & Wear NHS Trust Miss Vivienne Josephine Susan Jeffrey Care Home 5 Category(ies) of Learning disability (5) registration, with number of places McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of persons for whom residential accommodation with board and care is provided at any one time shall not exceed 5 men or women One Resident with dementia (DE), may be admitted, however no further admissions outside category LD to be admitted without consultation with CSCI. One person, LD over 65, may be admitted. Date of last inspection 20th December 2006 Brief Description of the Service: McNulty Court is a purpose built home in Dudley that provides care and support for up to five people who have a learning disability. At the time of the inspection there were four ladies living at the home. Two of these ladies also have a physical disability. The home is set in its own grounds and offers lots of space for the residents. Dudley is on the outskirts of North Tyneside and is conveniently placed for good road links to all parts of the area; this enables the residents to enjoy a good range of social leisure and educational opportunities. Copies of the Home’s Statement of Purpose and this Commission’s inspection reports were available in the Home. The current scale of charges was between £1261 and £1495 per week. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 20th December 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 6th and 26th November 2007. During the visit we: • • • • • • Talked with people who use the service, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: The people who live in the home and are able to say what its like, say that they like it there and say that the staff always listen to them. One said “As far as I’m concerned, I am happy with everything”. There is good information about the home available to anyone who wants to use this service. The home is careful to make sure it can meet the needs of the people who live there by carrying out a detailed check of what they need to be happy and safe in the home. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 6 It then draws up a clear plan for how it will meet those needs. To do this, it asks the views of the people who live there and the views of other people help care for them, such as social workers and doctors. People living in the home can enjoy life and take some risks, although risks are carefully thought about. People living in the home can choose what activities they want to do, and how they spend their day. They use local shops and facilities, and are part of the local community. People living in the home have lots of contact with their families and their friends. They are told about their rights and responsibilities, and are treated with respect by the staff. There is a healthy and enjoyable diet, and people enjoy their meals. People feel that they know who to tell if they are not happy with something in the home. The building is pleasant, and there is plenty of room. It is kept looking very nice and is clean and tidy. Staff are given lots of support and supervision, so they can talk about any problems they have with the work and give better help to the people who live in the home. The home is well managed. The manager is very experienced and qualified. What has improved since the last inspection? What they could do better: Some staff still need training in the safe handling of medicines, and the recording of medicines given needs to be tightened up. Staff must be better trained in protecting the residents from abuse, and must always follow the home’s policies in this area. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 7 Staff must also be given better training in how to meet the individual medical conditions of the people who live in the home. The home must be able to show its staff recruitment and selection records, to show it is properly protecting the residents from unsuitable staff. The home has not yet brought in proper ways of looking at how the care is given in the home, and how it can be improved. It must find better ways of asking the people who live in the home, and their relatives, what they think about their care, and how it can be improved. 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. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 8 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 McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 9 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 and 2. People who use the service experience good quality outcomes in this area. People thinking of coming to live at the home are given good information, set out in a way that helps them understand it. Their needs are also carefully looked at before they come into the home, so that the staff know that they can give the care needed. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information about the Home: All the information that someone who was thinking about coming to live in the home needs is clearly set out in the home’s ‘statement of purpose’ and the ‘service users’ guide’. These documents use pictures to help people understand the information clearly. Both service users who returned surveys said that received enough information about the home before they moved in. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 10 Assessments of Need: The home obtains detailed assessments of the needs of any service user coming to the home. We saw examples that included a very detailed ‘physical well-being’ assessment, completed by a Community Nurse; an Occupational Therapist assessment; and a comprehensive ‘risk management’ plan. The home also carries out a range of assessments, so that it can be sure that it can meet all the needs that a person may have. This gives them the evidence to decide whether a person can be safely admitted to the home. The assessments seen include assessments for risk, moving & handling needs, personal needs and wishes, and skin care. The need for all assessments to be signed and dated was discussed. The home attempts to make clear what information about a resident has come directly from the resident, and what has been given by family or professionals, on behalf of the resident. This is good practice. There was plenty of evidence that people thinking of coming to live in the home are given opportunities to visit the home, to stay for a trial period, and to get to know staff and residents before making a final choice about moving in. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 11 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. People who use the service experience good quality outcomes in this area. Each service user has a detailed plan for their care, which is kept up to date. Service users are actively encouraged to make as many decisions about their lives as they are able to. Staff help those who are not able to make clear decisions. Service users are helped to live life to the full, including taking carefully assessed risks. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Care Plans: The home uses the ‘Care Programme Approach’ (CPA) to meet the needs of its service users. This is a ‘multi-disciplinary approach; that is, an approach that McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 12 includes input from all professionals involved in the care of the service users, as well as the service users themselves. It results in a comprehensive and detailed ‘overview’ care plan. Multi-disciplinary meetings are held every six months to look at how well the care plan is working, and to make any necessary changes. There was evidence that service users have input into these meetings, where they are able, and their views taken seriously. An example of this was where a service user asked for more staff support in going to local shops, and this was then included in her care plan. Care plans also take account of equality and diversity issues. Service Users’ Decision Making: The home tries to use a ‘Person-centred’ approach at all times. Monthly house meetings are held. Minutes showed that the views of its service users are actively sought and are seriously considered. Service users who are unable to communicate their views verbally are also included in the meetings. Meetings discuss outings, shopping needs, social activities, menus and meals, and other parts of the daily routines. There was evidence that service users can and do add to the agenda, and that their comments lead to changes (for example, in the menus). Service users are asked on a daily basis what they want to do, and there are sufficient staff to allow for different service users to do different activities. One service user attends a monthly advocacy group. Risk Assessments: The home’s policy is to accept that risks are part of everyday life and cannot be completely eradicated. However, there is a good system of detailed and thoughtful risk assessments that seek to strike the right balance between safety and independence. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 15, 16 and 17. People who use the service (service users) experience good quality outcomes in this area. Service users are able to take part in activities that they choose. Service users are encouraged and supported to use local shops and facilities, and are part of the local community. Service users have good support from their families and can make and keep personal friendships. Service users’ rights and responsibilities are recognised and respected. Service users have a healthy and enjoyable diet, and enjoy their meals. We have made this judgement using available evidence including a visit to this service. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 14 EVIDENCE: Age-, Peer-, and Culturally- Appropriate Activities: Each service user has an assessment of their leisure activities. There are separate ‘timetables’ of activities for the more mobile and independent service users, based on their assessed needs and abilities. One person is independent enough to decide her day’s plans and to book her own taxi. There was evidence of staff finding out more and more about a person’s interests, and helping them meet their hobbies and interests. Activities include needlework, knitting, watching DVD’s and videos, use of a laptop computer, arts and crafts, seasonal activities such as making Christmas cards and shopping. Music and sensory equipment is available in the home’s conservatory. Outside the home, service users go line dancing and to disco’s, go walking, go to the theatre and shopping. One person attends church weekly Professional aromatherapy is given, in-house, every week. Both service users who returned surveys said that they can do what they want during the day, in the evenings and at weekends. Contact With Local Community: There was anecdotal and documentary evidence that staff support service users to access local shops and other facilities. Service users are assessed on their ability to get on with others and support given, where necessary. Service users have a good range of holidays and trips out. Trips this year included Seahouses, Bamburgh, Edinburgh, and more local places of interests such as Plessey Woods and the Metro Centre. Holidays include Haggerston Castle and Melrose. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 15 Appropriate Family, Social and Sexual Relationships: All service users have support from their families. Relatives are free to call in at any time, and there are no visiting restrictions. One service user has made good friends at the day centre she attends and they are also welcome to visit at any time. Rights and Responsibilities: All service users have individual contracts. Staff talk them through the contents, and tell them about their rights and also their responsibilities. The home’s ‘statement of purpose’ and ‘service users’ guide’ are available to service users and explain all about the home. These documents include pictures to make them easier to follow. This is good practice. The home is also hoping to produce a DVD to introduce and describe the home to people who may be thinking about coming into the home. One service user goes out and about of her own accord, and is being offered her own front door key. Staff knock on service users’ bedroom doors, give them their mail, address them by their preferred form of address and encourage visitors. Service users have keys to their bedroom doors and can choose when they use their rooms. They can smoke and drink, if they choose (this is in their contract). Diet and Meals: Menus cover a four-week period, and are reviewed every three months. Service users are involved in drawing up the menus and their joint and individual choices are incorporated, as much as possible. Staff will also cook a separate meal for any service user who doesn’t want what is on the menu for a particular meal. A cooked breakfast is available daily. Staff try to incorporate five portions of fruit and vegetables in the daily diet. Staff showed knowledge of the dietary likes and dislikes of each individual service user. McNulty Court DS0000000377.V352864.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. People who use the service experience adequate quality outcomes in this area. Service users usually receive personal support in the ways that they need and choose, but some areas need reconsidering, to maximise choice. The physical and emotional health care needs of the service users are met. The systems for dealing with medications need to be improved in some areas We have made this judgement using available evidence including a visit to this service. EVIDENCE: Personal Support: Personal care plans and reviews show that service users are consulted and included, as much as is possible, in their personal care and support. Both service users who returned surveys said that their carers always listen to and act on what they say. Both said that staff always treat them well. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 17 The service users choose what to wear, and when to get up and go to bed. There was discussion over the merits of using a mobile hairdresser as against using a local salon, and about the degree of choice that one lady is able to exert over having her hair cut. The involvement of an independent advocate is recommended for the relevant service user. Physical and Emotional Health Needs: There was good documentary evidence in the care records that service users’ physical and emotional health needs are fully assessed and properly addressed. Specialist assessments (for example, from an occupational therapist) are obtained where necessary and care plans follow this specialist advice. Clear and detailed records are kept of all visits to or from health professionals, and the attached district nurse’s inputs are also detailed. Medication Systems: None of the current service users take responsibility for their own medications. The home uses the ‘monitored dosage’ system of medication. Each service user has a record of their prescribed medicines, with the names of each medicine, its purpose, and any possible side effects. The majority of care staff have had ‘safe handling of medication’ training: new staff are awaiting the allocation of this training. This must be arranges as a priority. Study of the Medication Administration Records (MAR) showed that the practice for what is to be recorded when an ‘as and when required’ drug is not required was not clear. Nor was the policy on recording the administration of ointments to service users clear, as this was not being recorded in the MAR. A list of staff names and initials used in the MAR was in place by the end of this inspection. This is to aid the weekly internal drugs audit. McNulty Court DS0000000377.V352864.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): Standards 22 and 23. People who use the service experience adequate quality outcomes in this area. Service users able to express their views feel that they are listened to and that staff act upon those views. Service users are not being fully protected from abuse, because staff have not always followed the home’s policy and procedure for reporting allegations of abuse. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Complaints/Residents’ Views: The Home has an appropriate complaints procedure. This was available in a format that could be understood by some of the residents. Neither of the two service users who returned surveys said that they knew how to make a complaint, but both said they knew who to speak to if they were unhappy. Both also said that the staff always listen and act on what they say. No complaints have been received in the past year. This was discussed with the manager and a ‘feedback’ book has been introduced, to record views and opinions that fall short of being complaints. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 19 Protection From Abuse, Neglect and Self-Harm: It was a requirement of the last inspection report that the Registered Persons must take action to ensure that the Home’s adult protection policy and procedures are complied with at all times. This has not been fully carried out. Two allegations of abuse have been made in the past year. In one instance, an allegation about the conduct of a member of staff was made to another staff member, who did not report it immediately, nor according to the home’s policy. This had lead to the service user being inappropriately interviewed by the wrong person. In the second situation, the home’s policy of immediate reporting of any allegation of abuse to Social Services was again not followed. It was recommended that the manager organises regular ‘trial runs’ of the home’s ‘safeguarding’ policies and procedures, so that weaknesses are picked up in a safe scenario, rather than exposing service users to risk. All staff have been booked to attend refresher training in the safeguarding of vulnerable adults, to be completed by the end of March 2008. It was a recommendation of the last inspection report that, in order to ensure that all service users are protected from harm, staff have Criminal Record Bureau checks carried out at 3 yearly intervals. This is discussed under standard 34, below. McNulty Court DS0000000377.V352864.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 and 30. People who use the service experience good quality outcomes in this area. Service users live in a purpose-built home that is comfortable and homely, and that is safe. The home is clean, hygienic and pleasant. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Environment: A tour of the building showed it to be well furnished and decorated, and kept in good repair. It is comfortable and spacious. The issue of wedging open bedroom doors was discussed and a safe alternative has been quickly ordered, in the form of a device that holds a door open, but McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 21 automatically releases and shuts the door, should the fire alarms go off. This will improve the safety of the service users. Hygiene: The standard of hygiene in the home is good. All staff take responsibility for the home’s cleaning schedule. An odour caused by incontinence has recently been removed by the use of a better carpet cleaner, and the replacement of one bedroom carpet. The home is now odour-free. McNulty Court DS0000000377.V352864.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): 32, 34, 35 and 36. People who use the service experience adequate quality outcomes in this area. Service users are supported by competent and qualified staff. The home could not demonstrate that its staff recruitment practices fully protect the service users. Staff have not been given enough training to meet all the needs of the service user group. Service users have the benefit of having staff who receive regular supervision and support. We have made this judgement using available evidence including a visit to this service. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 23 EVIDENCE: Staff Competence and Qualifications: Nine of the 14 carers now hold the National Vocational Qualification (NVQ) level 2 in care. This exceeds the required 50 of care staff. Another 2 staff are studying to achieve this qualification. Staff Recruitment: It was noted that the home’s policy on recruitment and employment was nearly ten years old. The manager said that all the Trust’s policies are in the process of being reviewed and revised. It was a requirement of the last inspection report that the Registered Persons must ensure that at all times records are available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. This requirement included staff recruitment and selection records. This has not been carried out. These records are still being held at the Trust’s headquarters, and were not able to make available to the inspector. This requirement is repeated in this report, as it is important that the Trust can show that it is careful and rigorous in how it employs new staff. A recommendation was also made that, in order to ensure that all service users are protected from harm, staff have Criminal Record Bureau checks carried out at 3 yearly intervals. It was not clear that this recommendation has been carried out. It is repeated in this report. Staff Training: It was a recommendation of the last inspection report that staff are provided with training in meeting the specific disabilities and conditions of residents such as early on set dementia and epilepsy. This has not been fully carried out. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 24 Twelve staff still require training in meeting the needs of people with early onset dementia and Downs’ syndrome; only two have been given this training. Similarly, another three staff are still awaiting training in epilepsy. The manager reported that the recent substantial mergers of NHS Trusts to form the current Trust have delayed the training programme, but that it is now beginning to settle down. The manager is aware that, although the home has a condition of registration that it may admit one person with Dementia, this must not take place before the appropriate staff training is given, and that the home’s statement of purpose would also need to be amended to reflect this. There is an overall staff training and development plan, drawn up from the needs identified in an annual audit of staff training needs. This includes statutory training needs. Personal development training for staff is addressed using the Trust’s ‘Knowledge and Skills Framework’. Individual training plans are drawn up between the staff member and the manager. This is done in a commendably thorough fashion and identifies specific training needs, with target dates for completion. This is good practice. However, the manager is dependent on the provision of in-house courses by the Human Resources department, and has no budget to seek external training. Equality and diversity training forms part of each staff member’s personal development plan. All staff will have received this training by the end of January 2008. Staff Supervision: Records showed that care staff receive formal supervision every two months, in line with the expected frequency. The manager is supervised monthly. There is a set agenda, covering service users’ needs and progress; personal staff issues; and reflection on personal care practice. The minutes of these sessions showed evidence of being genuinely interactive, and both parties sign the minutes. Action points are identified. Annual appraisal takes the form of the personal development plan approach and the ‘Knowledge and Skills Framework’ described above. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 25 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 and 42. People who use the service experience adequate quality outcomes in this area. Service users benefit from a well run home. The home cannot fully demonstrate that the views of its service users underpin all the self-monitoring, review and development by the home. The home has improved its promotion and protection of the health, safety and welfare of service users, but this needs to be further developed. We have made this judgement using available evidence including a visit to this service. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 26 EVIDENCE: Running of the Home: The manager has 27 years experience working with this client group, including 9 years as assistant manager and 3 as team leader. She holds the Certificate in Learning Disabilities (a two-year course), as well as National Vocational Qualification (NVQ) level 4 in both care and management. She is an NVQ assessor. Five staff returned surveys as part of this inspection. Four said that they are ‘always’ given up to date information about the needs of the people they care for; one said ‘usually’. All five said that they are given relevant training. All five said that they meet with their manager, either regularly or often, to be given support and to discuss how their work is going. Service users’ Views: It was a requirement of the last inspection report that the registered Person must establish and maintain a system for reviewing at appropriate intervals, and improving the quality of care provided at the Home. This has not been carried out, as yet. However, the manager said that an annual Quality Assurance scheme is being drawn up. This requirement is repeated in this report. Current quality systems include monthly meetings with the people who live in the home. They are encouraged to set their own agenda, where able. Meetings are minuted and signed by the two service users able to do so. The agenda usually includes social activities, menus, medication issues, etc. there was documentary evidence that staff respond to service users’ suggestions. There are monthly visits by the home’s line manager, who records her discussions with service users. It was also a requirement of the last inspection report that the registered person shall supply to the Commission a report in respect of any review of the quality of care provided at the Home and make a copy available to service users. This has not been carried out, but this will form part of the new quality system, to be introduced. This requirement is repeated in this report. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 27 Currently, reviews are carried out using the service users’ ‘personal development plan’ documents. These takes place, formally, every year and are attended by the care manager (but, informally, every three months, being minuted in the person’s daily notes). These reviews always try to include relatives, who are always invited. Another requirement of the last inspection report was that the system for reviewing the quality of care provided at the Home must provide for consultation with service users and their representatives. This has not been carried out. Again, it was stated that this would form part of the proposed new quality assurance system. Again, this requirement is repeated in this report. Health, Safety and Welfare of Residents: Evidence was found of the regular servicing of portable electrical equipment, electrical circuits, hoists, fire detection, heating and gas appliances. Fire fighting equipment had not been serviced since July 2006, but this was arranged by phone during this inspection. There is a detailed and comprehensive policy on preventing infection and managing infection control. It was a requirement of the last inspection report that the Registered Persons must ensure that all staff take part in fire drills at the frequency agreed with the Fire Authority. This has been carried out. Quarterly in-house fire drills were demonstrated. There is also a daily check of the fire panel; weekly checks of fire alarms and emergency lights; and monthly checks of fire fighting equipment. It was a recommendation of the last inspection report that, in order to improve the monitoring of staff participation in fire drills and fire prevention training, individual records be kept for each member of staff; also, that copies of maintenance checks/inspections of the Home’s installations and equipment should be available in the Home for inspection. This has been partly carried out. However, copies of maintenance checks and/or inspections were still not available for inspection within the home. This part of this requirement is repeated in this report. McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 28 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 3 2 3 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 3 23 2 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 3 33 X 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 X 2 X X 2 X McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 29 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 YA20 Regulation 13.2 Requirement The policy on recording the administration (or otherwise) of ‘as and when required’ medicines in the Medication Administration Records must be clarified. The policy on recording the administration of ointments in the Medication Administration Records must be clarified. 2. YA20 13.2 Those care staff have had not yet had ‘safe handling of medication’ training must be given this training as a priority. The Registered Persons must take action to ensure that the Home’s adult protection policy and procedures are complied with at all times. 28/02/08 Timescale for action 31/12/07 3. YA23 13 31/12/07 4. YA34 17(3)(b) The Registered Persons must 31/12/07 ensure that at all times records are available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. The Registered Persons must DS0000000377.V352864.R01.S.doc 5. YA39 24 28/02/08 Page 30 McNulty Court Version 5.2 establish and maintain a system for: reviewing at appropriate intervals; and improving, the quality of care provided at the Home. The registered person shall supply to the Commission a report in respect of any review of the quality of care provided at the Home and make a copy available to service users. The system for reviewing the quality of care provided at the Home must provide for consultation with service users and their representatives. 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 YA32 Good Practice Recommendations Provide staff with training in meeting the specific disabilities and conditions of residents such as early on set dementia and epilepsy. In order to ensure that all service users are protected from harm it is recommended that staff have Criminal Record Bureau checks carried out at 3 yearly intervals. Copies of maintenance checks/inspections of the Home’s installations and equipment should be available in the Home for inspection. The involvement of an independent advocate is recommended for one service user regarding issues such as hairdressing. 2. YA23 YA34 YA42 3. 4. YA18 McNulty Court DS0000000377.V352864.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection 4th Floor St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 McNulty Court DS0000000377.V352864.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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