Inspection on 28/02/04 for Medihands Healthcare (2)

Care Homes For Adults (18 ­ 65)Medihands Healthcare (2)2 Westbury Road New Malden Surrey KT3 5BEUnannounced Inspection28th February 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Medihands Healthcare (2) Address 2 Westbury Road, New Malden, Surrey, KT3 5BE Email Address Tel No: 020 8404 4108 Fax No:Name of registered provider(s)/Company (if applicable) Mrs Jayashree Sawmynaden Name of registered manager (if applicable) Mrs Jayashree Sawmynaden Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3), Mental disorder, excluding learning disability or dementia (3) Registration number G040000165 Date First registeredDate of latest registration certificate 30th July 2002Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionYes NO 30.10.03 If Yes Refer to Part CMedihands Healthcare (2)Page 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 328th February 2004 10:00 am Paul MaloneyID Code097769Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mrs Sawmynaden the time of inspectionMedihands Healthcare (2)Page 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementMedihands Healthcare (2)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Medihands Healthcare (2). The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Medihands Healthcare (2)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The home provides long term care for a small number of people with severe and enduring mental illness. It aims to support service users in becoming independent. It provides good levels of support to service users. The accommodation is of good quality and the manager is well organised in supporting the needs of both service users and staff.Medihands Healthcare (2)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of Home (Standards 1-5) Two Standards were inspected. One Standard was fully met and one Standard was partly met. The Service Users Guide must be removed to make it more accessible. Prospective service users are encouraged to visit the home as much as possible. Individual Needs and Choices (Standards 6-10) One Standard was inspected. The Standard was fully met. Staff encourage service users to make choices about their daily routines. Lifestyle (Standards 11-17) Three Standards were inspected. Three Standards were fully met. The service users spoke highly of the care provided both at the home and at the day programme. Care plans show evidence that staff support service users in managing personal care and leisure activities. The food provided is nourishing. Personal and Healthcare Support (Standards 18-21) Two Standards were inspected. One Standard was fully met. One Standard was partly met. There was regular oversight for the service users from the community psychiatric services. The method of tracking a service users weekend medication must be drawn up. Concerns, Complaints and Protection (Standards 22-23) One Standard was inspected. One Standard was fully met. There is a clear complaints procedure in place. Environment (Standards 24-30) One Standard was inspected. One Standard was fully met. Staffing (Standards 31-36) Three Standards were inspected. Three Standards were fully met. The organisation has a clearly defined job description and employment procedures. There is a good training profile for staff. There is a good supervision system of staff. There is a very well appointed bathroom in the home. Conduct and management of the home (Standards 37-43) Three Standards were inspected. Two Standards were fully met. One Standard was not met. The hot water system is at too high a temperature and must be reduced. The manager has Medihands Healthcare (2) Page 6 an open inclusive style. There is a wide range of policies in place.Medihands Healthcare (2)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 4 13 42 Hot water temperatures are to be checked and recorded weekly. 31.1.04Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Medihands Healthcare (2)Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 5 1 The registered person must produce a Service Users Guide in a format that is accessible. 30.6.0421220The registered person must produced a policy and procedure on the management of 30.6.04 medication taken outside of the home. It must train staff in this policy. The registered person must ensure that the hot water temperatures in the home are brought to safety levels. 30.4.0431242RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard *Medihands Healthcare (2)Page 9 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) Medihands Healthcare (2) YES NO NO YES YES NO NO NO NO NO YES YES YES YES NO NO NO YES NO YES 1 0 0 NO NO YES YES X X 28/2/04 10.00 3 Page 10 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Medihands Healthcare (2)Page 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 469.02 X Range of fees charged From To £ £ (per week) YES Any charges for extras Hairdressing, toiletries, clothing. If yes, please state what the extras are 2 Key findings/Evidence Standard met? The Service Users Guide was inspected. It is far too big as it involves large unwieldy files with many documents quoting from legislation or the homes procedures. Parts of the Guide were very good in that photographs of services eg: Post Office, shops and the local neighbourhood were provided. The home must consult the service users in ensuring that the Guide is accessible to them in terms of form and language. This issue is subject of requirement 1.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The manager confirmed that all prospective service users are encouraged to visit the home as often as practical. They would meet the staff and the other service users and have a meal in the home.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Evidence from one service user confirmed that the homes staff encourage service users to make choices about their own daily routine. Service users draw up their own routines which are part of the care plan.Medihands Healthcare (2)Page 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met?Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 3 Key findings/Evidence Standard met? The inspector spoke to one service user in the home at the time of the unannounced inspection. The service user spoke highly of the care provided in the home saying that he felt supported and looked after. He was able to have his food either in this home or in another care home nearby where there was more company. His brother visited occasionally and was also in touch by telephone. The service user would also visit his family. He attended a day programme on a regular basis at the local psychiatric day clinic. At the day centre, a good lunch was provided.Medihands Healthcare (2)Page 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. Key findings/Evidence Standard met? This Standard was not inspected at this inspection.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 17 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The four week rolling menu was seen and a diary of all meals eaten were recorded in the home. The service users confirmed that the food was enjoyable and varied.Medihands Healthcare (2)Page 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) XX0 Key findings/Evidence Standard met? The service user visits by his consultant psychiatrist on a three monthly basis. The consultant also attends the six monthly review in the home. There is also a weekly visit from the community psychiatric nursing service.Medihands Healthcare (2)Page 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met?Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home has a clear complaints procedure. This gives service users clear information on how to make a complaint. Staff encourage service users to comment on the care provided.Medihands Healthcare (2)Page 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence This Standard was not inspected at this inspection. NOX Standard met? 0Medihands Healthcare (2)Page 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This Standard was not inspected at this inspection. YES NO NO X X X X Standard met? 0 X XX X X XMedihands Healthcare (2)Page 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This Standard was not inspected at this inspection. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? There is one bathroom which the home is rightly proud of. There is a very large bath with gold painted taps.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? During the inspection, a copy was seen of the organisations pre-employment code of conduct that clarifies the expectations on staff when they are employed. This includes a confidentiality statement, enhanced CRB check and a willingness to comply with Medihands Policies and Procedures. This is a helpful document which is to be commended.Medihands Healthcare (2)Page 27 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? Evidence from one of the care staff shows that the home has a clear training profile. This includes courses on First Aid, food hygiene, health and safety medication administration training. The care worker has been attending Kingston college for his NVQ Level 2. He has been working at the companys large home to obtain evidence for his portfolio. The owner of the home is a NVQ assessor and profiles a series of lectures on mental illness and its history and treatment as part of the assignment for the staff undertaking NVQ Level 2. The classification of illness are examined along with case studies of past case histories. There are opportunities for service users to describe their clinical symptoms so that staff can more clearly understand the issues. Each staff member receives a certificate of attendance. The registered organisation has also arranged for a training company to provide NVQ training in its homes. Three staff are registered as assessors. Five staff in the company have almost finished their NVQ Level 2 and five more will begin soon. Other staff members of the company are considering undertaking GNVQ in Nursing. They will commit themselves to work for Medihands for three years.Medihands Healthcare (2)Page 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 29 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Evidence from one staff member on duty, the care manager and the owner of the company states that the four staff members at the home receive supervision on a two monthly basis. The session involves the following structure: Issues from the last session Keyworking issues Files of their keyworking clients Reviews of their clients and issues arising Training issues. Supervisions are written up on a form which is kept on the staffs individual personal file at the head office. Copies must be available for inspection at the home. Each staff member has an annual appraisal. During this process, the manager will examine the staff members activity over the past year, what progression has been made, what problems/issues have been addressed and what plans are being made for the future.Medihands Healthcare (2)Page 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. Key findings/Evidence This Standard was not inspected at this inspection. NO 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Staff spoken to during the inspection confirmed that the manager and the owner created an open, inclusive management style that was focussed on providing positive care for the service users. The manager was always available if any problems arose. On the day of the inspection, the manager had been called at 7am about a problem with the electricity and this had been solved within two hours.Medihands Healthcare (2)Page 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This Standard was not inspected at this inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 3 Key findings/Evidence Standard met? The home has in place a wide range of policies and procedures. Service users have access to all the policies and procedures.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 0 Key findings/Evidence Standard met ? This Standard was not inspected at this inspection.Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 1 Key findings/Evidence Standard met? The hot water system was measured during the inspection and the temperatures were too high. Temperatures were recorded at 55oC. The owner of the home agreed that the plumber would be contacted to reduce the temperatures of water in the home. The home must confirm that this has occurred to the NCSC. This issue is a subject of Requirement 2.Medihands Healthcare (2)Page 32 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This Standard was not inspected at this inspection.Medihands Healthcare (2)Page 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DatePaul Maloney Norma VieiraSignature Signature SignatureMedihands Healthcare (2)Page 34 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Medihands Healthcare (2)Page 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 28 February 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Comments and an Action Plan were not received from the Provider.Action taken by the NCSC in response to provider comments: Medihands Healthcare (2) Page 36 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 24/05/2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOYESYESOther: enter details here Medihands Healthcare (2)Page 37 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Medihands Healthcare (2)Page 38 - 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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