Inspection on 14/12/05 for Mellor House

This inspection was carried out on 14th December 2005.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mellor House 31/05/07

Mellor House 26/09/06

Mellor House 25/05/06

Mellor House 03/05/05

Mellor House 19/10/04

Mellor House 04/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Mellor House 80 Station Road Westcliff On Sea Essex SS0 7RQ Lead Inspector Mrs Sarah L Meddle Announced Inspection 14th December 2005 09:30 Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mellor House Address 80 Station Road Westcliff On Sea Essex SS0 7RQ 01702 437350 01702 437350 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) Royal Mencap (Housing & Support Services) Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Mellor House is a purpose-built home providing 24 hour residential care for up to eight adults with profound complex physical and learning disabilities. The home is situated within a residential area of Westcliff on Sea and is close to the towns of Southend and Leigh on Sea with views of the sea. There are good public transport links to the area and a railway station is within close walking distance to the home. Springboard Housing Association owns the home, and MENCAP provide the care. There are eight spacious single bedrooms with handwashing facilities all located on the ground floor. Assisted bathrooms are located within easy location to the bedrooms. There is a large lounge and dining room available. The kitchen is large and wheelchair accessible. A number of areas within the home have been refurbished and this includes the lounge, hallway and kitchen. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced so that the home could invite interested parties to partake. A poster was placed in the main hallway near where visitors sign in on entry to the home for fire safety purposes. The inspection took place over eleven hours in one day and staff, family members and service users were spoken with. Some time was spent trawling through necessary paperwork to assess whether any improvements had been made since the last inspection in May. The rest of the time was spent with staff and all service users and enjoying a disco with them. The home has introduced a personal care planning system, which is pleasing to note. This is still in the initial stage as not all parents have been able to take part. Staff need to have continued support with developing this system to ensure the process is regularly updated and understood. Staff have a difficult task of identifying service users personal wishes and goals due to their disability and difficulty in making their needs understood but if a multidisciplinary approach – including family members, day service staff, social workers and so on, is introduced this should make the task easier. Seven staff were spoken with during the day. Four out of a possible 15 staff returned a survey sent to the home by the CSCI. Generally positive comments were expressed regarding the working conditions. They also said that training opportunities are good. They were asked about the purpose of the home and what the home does well. Staff said that it was good that service users needs are put first and that they are all concentrating on the personal care planning system. Some staff said they felt they needed more support to do their job. All staff felt that they involved family members/relevant others well in all aspects of the service users lives as long as their rights were protected. At the point of writing the report, no responses were received from social workers or day service staff. However, these were surveyed as part of the previous inspection, as were the parents/family members/representatives. The home has experienced a significant period of change in recent years due to the lack of permanent management. This was addressed, with the appointment of a permanent experienced and qualified Manager, Ms Mabel Tuffour Quest, in January 2005. The CSCI are processing an application from MENCAP for her to be registered as Manager of the home. What the service does well: Mellor House staff works well with other agencies (health care professionals, formal day service staff) and takes advice to help the residents. The home gives equal opportunities to people applying for jobs. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 6 The Manager and staff generally listens and responds to suggestion for improvement. The home provides spacious living accommodation and single bedrooms for all the residents. Many areas of the home have been upgraded. Staff supervision was reported to take place regularly and staff spoken with stated that they found this useful. Residents (service users) changing needs have been identified and acted upon with professional opinions being sought where necessary. It was pleasing to note that the home uses the services of an independent advocate. What has improved since the last inspection? What they could do better: Relationships with residents families was reported by the Manager to have improved, however family members spoken with during the course of the inspection and subsequently did not agree. Overall their general opinion is that their interaction and involvement in the service users lives needs improving and for the Manager to be more available out of normal working hours although this is partly resolved but not accepted by family members, with a Deputy Manager vacancy being filled by a member of staff who has worked at the home for some time and who works weekends. Family members/representatives spoke of a number of ongoing issues/’niggles’, which should have been resolved by the home or organisation. It was strongly advised that the Manager and organisation concentrate on improving dealings with service users family/representatives to resolve the concerns of a discontented group of significant people in the service users lives, which is clearly affecting the general atmosphere in the home. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 7 The home needs to significantly improve the activities offered and taken up for service users both in the home and in the local or wider community. It was advised that the home needs to prioritise training for staff to enable them to be aware of service users needs as people and further develop their values on caring for people with complex needs/disability. The home should improve daily record keeping including details of the welfare of the service user and how they have spent their day. The home should train and support staff to understand the basic principles of normal life principals and values to enable them to understand the needs of the service users as individuals – looking at gender, age, culture, religion for example. The home must provide all staff with training in communication with people with complex disabilities as highlighted at the last inspection. Care plans, risk assessments need to be clearer, for example; dated and reviewed. Written evidence of service delivery to be improved (daily notes on what the resident has done and how they have spent their day). The home should provide a varied and nutritious diet and alternatives for special diets should be clearly identified. 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. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 The home demonstrated it generally meets the needs of individuals at the home by the actions taken/observed. Written material maintained in the home and involvement of others is not adequate to support this. EVIDENCE: The home provides prospective service users with a service user guide and statement of purpose. This needs to be updated to include the details of the Manager who has been in post for 11 months. No new service users have been admitted since the last inspection. Full assessments would be carried out prior to admission using MENCAP paperwork, and all parties are involved in this process where appropriate, including the service user, family members, social worker. Whilst these do not fully address those identified in the National Minimum Standards, future assessments for new admissions are reflective. Independent advocates have not been involved in this process but the home has now secured the services of an advocate. Due to the nature of service users complex disabilities the home has not been able to fully identify service user aspirations but their basic daily activities are addressed. The care plans, based on person centred planning (PCP), have not completed since the last inspection. It was suggested that the service users families, representatives or advocates are involved in information gathering to support the care planning system. Many parents, representatives spoken to Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 10 during the course of the inspection and subsequently have commented that they are not kept involved of the service users development as much as they used to. After the inspection in May 2005 the Organisation devised an action plan to address requirements and recommendations, which included more appropriate involvement of significant others and this does not appear to have been addressed. Some items in the care plans were not dated, nor was there clear evidence of reviews. Daily recording of the key activities and welfare of the service user needs to be improved. The staff group did not fully incorporate the ethnic and religious background of the service users. Revised contracts reflecting the NMS for Adults were now in place – one needed signing by the service user or their representative. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Information maintained is not sufficient, not reflective of the service delivered and does not fully reflect the needs of the individual. The home does involve the service user in some care planning. They need to demonstrate this more. EVIDENCE: Despite their complex disabilities and communication difficulties, the home attempts to identify service users personal goals and wishes through the person centred planning (PCP). However normal life principles are not reflected and this is primarily due to the lack of training or understanding of staff as to the individuality, disability and needs of the service user. It was discussed and acknowledged by the Manager that staff would benefit from effective training in valuing people and disability. She stated that all staff attended training on person centred planning (PCP) in June 2005. John O’Brien’s 5 Accomplishments would be a further useful tool to enable the staff to fully understand the needs of each service user as a person and as an individual with a disability. An example of how the home service provision is let down is one service user who sometimes goes out with a friend at weekends had this down in their Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 12 activity plan as the only activities available to them. The home really needs to improve the activity options available both in and out of the home. Also this service user had a page for ‘FRIENDS’ in their PCP and the staff member involved in completing this had put only the names of 14 paid care staff at the home and one personal befriender. It appeared that no attempt had been made to identify further acquaintances such as at formal day services or others resident in the home or from that persons past. Service users are involved in the devising of the individual care plan where practicable. These basically reflect assessed needs, likes, dislikes and daily living activities. Photographs of the service users enjoying and taking part in activities to illustrate the care plan further is positive. The care plans need to show the dates devised and any reviews. Care plans (PCP) were not amended depending on the changing needs of service users. These did not reflect goals and aspirations. Staff had spent time colouring in the different pages of one PCP but not actually completing them. Generally daily notes kept on the welfare of the service user and how they have spent their day was not always completed and other relevant information was limited. However, on other occasions, comments were informative and detailed. The Manager stated that a senior service Manager was exploring training for staff on report writing. Risk assessments are included but these are basic and lack significance, dates and review. Revised risk assessments were in place, carried out involving the key worker responsible for each service user. However these were not fully detailed, as these did not have management strategies in place – for example ‘if X does not want to eat’ action – ‘encourage X to eat’. This is not enough and does not explain the intricacies of the process. The Manager said that staff had recently received training in carrying out risk assessments. It was clear she needs to ensure staff understood the training and give further guidance. The home has secured the services of an independent advocate for each service user and this is very positive. The Manager stated she holds regular meetings for family members to attend, both jointly and individually. Some parents have been unable to attend. Family members reported that they felt that the Manager was not as available as they think she should be, including weekends. A part time deputy Manager is in post, which should help as she works weekends and would be available to answer parents’ queries. Information held on service users is stored appropriately. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 The home needs to demonstrate more fully the opportunities for activities for service users and ensure they fully participate and contribute to their local community. Service users are supported to maintain personal and family relationships. Daily routines are based around the service users needs. Meals provided need to reflect good nutritional principles. EVIDENCE: Some activities were reported to be available such as outings to the pubs and local theatre. The person centred plans did show pictures of service users enjoying some activities. However, service users representatives felt that the service users were not offered the extensive activities reported to be available. The home must ensure this matter is addressed. At weekends the staffing levels are maintained to support 1:1 activities to take place, which is positive to note. A number of service users attend formal day services, which enables them to partake in activities with their peers. No service users are involved in paid work. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 14 Family members have a strong presence in the home and actively support the service users. An independent advocate is available to ensure an objective view to support the service users rights is presented. Where practicable service users personal rights within the home are supported and respected, although this would be demonstrated better by the homes recordings and staff understanding of valuing people. Service users are supplied with adequate food stocks. It was discussed that the menus presented identified that the menu was repetitive, not nutritionally varied and it did not detail any fruit or vegetables. The Manager stated that this was mostly reflective of service user likes. She agreed to ensure that items such as vegetables and fruit which are readily available, are added to the menu. A nutritional record is required to ensure that records for each individual shows the diet is satisfactory. Alternative selections and special diets were not highlighted adequately. The kitchen cupboards and worktops have been replaced. The cooker and hob was in need of a thorough deep cleanse and this was highlighted at the last inspection. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Service users personal and healthcare support is well managed. Written information maintained by the home is not reflective of the full service delivered. Relevant paperwork was not always maintained. EVIDENCE: Care documentation highlights service users personal care needs. The home has introduced a keyworker system and they have responsibility for organising healthcare appointments and other necessary visits. It was encouraging to note through discussion and observation that service users changing needs are recognised but it was disappointing that care records do not adequately reflect this. Policies are in place to support any service users wishing to manage their own medications. Currently no service users do. Despite significant medication errors in the past, Medication Administration Records (MAR) were well maintained. A problem with staff not signing for medication in the past was not apparent during the inspection. The Manager stated that both she and the Deputy Manager regularly audit the MAR sheets and deal with any anomalies immediately. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 16 Medication risk assessments and protocols were not clear or reviewed where applicable. Advice from a pharmacist through the PCT is advised. The medication fridge now has a lock. The home is in the process of completing information gathering from family members regarding the ageing or illness wishes of the service users. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The organisation responds to complaints about the service. Recent concerns have highlighted the need for the home to communicate more effectively with families. Staff must have the relevant knowledge to effectively protect the service users from harm or abuse and the home needs to ensure that the training given has been understood. EVIDENCE: The home has received two complaints since the last inspection regarding food purchasing and attending appointments and these were dealt with by MENCAPs Head Office. No evidence of the outcomes of these investigations were available in the home. A number of complaints/concerns have been received by the CSCI during the inspection process, about the level and quality of service delivered, availability of the Manager, staff competencies and lack of involvement of family members in the day to day management of the home and service users lives. Robust policies are in place to protect service users from harm or abuse. Service users were unable to communicate whether they felt safe. 16 staff have attended training in the Protection of Vulnerable Adults from Abuse in June and December. The training now includes a test at the end to ensure staff have understood. It was advised that the home carries out refresher updates either through meetings, training or supervision for example, to ensure staff understand their responsibilities on identifying and reporting procedures of suspected abuse. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 The home provides sufficient space and facilities to meet service user needs. The lounge is bright and spacious and provides a view of the sea for those not using wheelchairs. Many areas of the home have been upgraded. Some bedrooms would benefit from being next in the phase of refurbishment. EVIDENCE: Service users at Mellor House are provided with individual spacious bedrooms, bathrooms and corridors wide enough for self-propelling a wheelchair for example. There is a large lounge room, which has recently been refurbished including curtains carpet and settee/chairs. There is now adequate seating for staff and visitors to sit with them. There was some specialist seating available and the Manager stated there was more to be ordered. It was pleasing to note that the Home had addressed this matter from the last inspection, and that service users do not need to stay in their wheelchairs for long periods. It was concerning to note that domestic hours had been cut meaning that care staff are carrying out this task. Although there were no service users at home during the early part of the inspection, one member of staff spent much of their early shift carrying out necessary domestic duties. This would certainly Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 19 have an impact on care service delivery at the weekend or holidays from the day service. There were no unpleasant odours noted on this visit. The carpet in the main hall had been replaced. Some bedrooms would benefit from redecoration. The garden had been tidied but appears inaccessible to service users. Staff and families confirmed that they do not really make use of the garden in the better weather. The homes vehicle has been serviced but it is still not being used effectively and this is disappointing. Currently there is only one member of staff able to drive it but this is extended to service users family members whom the home will insure. The home would benefit from a more reliable, modern, larger vehicle, which would enable more than one service user to access the community. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 The Manager reported good staff morale and working relationships. Staff spoken with confirmed this. Training opportunities were good. The rota was not maintained accurately. The organisations recruitment checks were not effective. EVIDENCE: Job descriptions are available detailing staff roles and responsibilities. The Manager reported that six to seven staff are undertaking the NVQ in care at Level 3. A number of staff have worked at the home for some time. The staff rota had dates missing and on occasions there was more than one rota for the same week with different hours worked. The Manager must ensure that one main rota is available and that she signs it as a true record of hours actually worked. Codes used must have clear description detailed. All agency staff need to have their full names on the rota and the home needs to get effective confirmation from the supplying agency, that regulatory information is available, or request it on behalf of the staff themselves. The home needs to ensure that the service users night care needs are effectively met with adequate numbers of staff on duty. The Manager stated that service users were having a reassessment of their needs on the Friday following the inspection to address the night-time staffing. The home should ensure that adequate staff are on duty if the needs of the service users dictate Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 21 this and not wait until the funding is agreed. It was discussed that the home should improve the general record maintenance on the needs of the service users and this would support any request for increase in finances. There continues to be a significant reduction in the use of agency staff. The organisation has not ensured that appropriate staff references are taken up. On one staff file it was noted that an applicant now employed at the home, provided two referee’s mobile phone numbers, rather than the services details for example the landline phone number of an agency. Another applicant’s reference was from their family member giving an employment reference and this was not declared on the referee’s details on the application form. This irregularity did not take much time to discover during the inspection. Instructions detailed by the Home Office on employment hours have been investigated and are followed. The Head Office now takes regular checks on student working permits. The home had not been provided with the required information on a new member of staff by the organisation and this is unacceptable. Original certificates of CRB checks were not retained in the home. Staff receive adequate supervision approximately every 2 months and stated that they found it beneficial. Staff stated that they had recently received training in POVA, however there were no records or certificates to evidence this. The Manager stated that other training is due to be booked. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43 The Manager has been in post for 11months. Improvements in written record keeping relating to care service delivery must be evident. The best interests of service users appear to be safeguarded however the written evidence does little to substantiate this. EVIDENCE: The Manager has many years experience of managing care homes for people with enduring mental health issues. Because of other issues to be dealt with such as staffing and building issues, relationships with service users families and relevant records relating to care have not been prioritised and this must now be addressed. Family members are unhappy that the Manager does not work weekends or is not available out of normal office hours. On looking at one rota for December 2005, it appears that the Manager was on the rota to start work at 7.30am – 3pm one day and 2pm until 9pm on another. When the Mellor House first opened in 1996 the parents and service users were used to having a Manager who worked shifts and was available at weekends. With the changes in Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 23 legislation and pressure from the organisation and with the home the size it is and amount of staff and service users, having a Manager working hands on doing shifts no longer works successfully. The home has attempted to address this by appointing a member of staff as Deputy Manager who works weekends. It was reported that families are not informed when the Manager is to be away. She has had a few periods of extended leave this year and parents have been left unhappy that they were not informed and that other arrangements were in place to cover these absences. The home needs to address this matter urgently. The action plan sent to the CSCI has a number of outstanding matters, which have not been addressed within the timescales Some records required by regulation were well maintained. As previously discussed, records relating to care delivered to service users is poor. The organisation maintains effective policies and procedures. Quality assurance monitoring had not been carried out and this must be addressed. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 1 3 2 Standard No 22 23 Score 1 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 1 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 1 LIFESTYLES Standard No Score 11 3 12 1 13 3 14 1 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 1 1 1 1 3 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mellor House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 1 3 3 3 3 DS0000015510.V262257.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4, 5 & 6 Requirement The registered person must ensure that the information provided to prospective and current service users is up to date. This includes the Managers details on the Statement of Purpose and Service User Guide. A copy to be sent to the CSCI. This is outstanding from the previous inspection on 3rd May 2005 The registered person must ensure that the staff individually and collectively have the skills and experience to deliver the services and care it states it offers. Staff to demonstrate they can communicate effectively. The registered person ensures there is a care plan based on the assessment which describes the needs, goals and aspirations which is drawn up with the service user and relevant others. This is to be updated regularly to reflect changing needs. This is outstanding from the previous inspection on 3rd May 2005 The registered person must DS0000015510.V262257.R01.S.doc Timescale for action 01/01/06 2 YA3 18 & 19 31/03/06 3 YA6 17(1)(a) Sch 3 31/03/06 4 YA8 13 (4) 31/03/06 Page 26 Mellor House Version 5.0 5 YA14YA12 6 YA17 7 YA22 8 YA30 9 YA33YA32 ensure there are effective risk assessments in place within the context of the care plan and that risk management strategies are in place. These need to be updated regularly. This is outstanding from the previous inspection on 3rd May 2005 16 (2) The registered person must (m) ensure that appropriate activities, education and occupation are offered to service users. This to reflect racial and cultural diversity of the individual service users. 16(2)(i)17 Provide wholesome and & Sch 4 nutritious food which is varied and reflected in the nutrition record for service users. Identify any special diets. Ensure the kitchen equipment – the oven and hob is thoroughly cleansed. This is outstanding from the previous inspection on 3rd May 2005 22 & Sch The registered person must 4 ensure the complaints procedure is followed and that information relating to complaints is recorded effectively. 18 The registered person must ensure adequate ancillary support is provided which does not affect the day-to-day care service delivery. 17 & Sch The registered person ensures 4 that the home has an effective staff team who have the necessary competencies, qualities and complementary skills to meet the service users needs. The home must ensure that there is adequate support for service users, particularly at night-time, dependent on the needs of the service users. The home must provide an accurate DS0000015510.V262257.R01.S.doc 31/03/06 28/02/06 28/02/06 31/03/06 01/01/06 Mellor House Version 5.0 Page 27 10 YA34 19 & Sch 2 11 YA35 18 12 YA39 21 & 24 13 YA43 12 record of staff working in the home and whether the rota was actually worked. Ensure effective recruitment checks are carried out - this to include adequate reference information and original CRB certificates. This is outstanding from the previous inspection on the 3rd May 2005 The registered person needs to ensure that effective staff training programme is in place to identify the benefits for service users fulfil the aims of the home and meet the changing needs of the service users – this to include communication tools, valuing people, equal opportunities, including disability equality and race equality. The registered person must undertake full quality assurance and quality monitoring of the service ensuring the views of service users, family members/representatives, staff and other interested parties are gathered. This is outstanding from previous inspections The registered person must ensure that the home is conducted to effectively maintain good personal and professional relationships with service users and their families/representatives. 01/01/06 30/06/06 31/03/06 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 28 No. 1 2 3 Refer to Standard YA6YA2 YA5 YA23 Good Practice Recommendations Family carers/representatives interests and needs are taken into account when developing the assessment and care plan subject to the rights of the service user. The terms and conditions of residency at the home need to be signed by service users or their family member/representative. Ensure staff regularly review their roles and responsibilities in relation to the protection of vulnerable adults from abuse. Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mellor House DS0000015510.V262257.R01.S.doc Version 5.0 Page 30 - 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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