Inspection on 26/09/06 for Mellor House

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 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 25/05/06

Mellor House 14/12/05

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 Sarah Axam & Sarah Meddle Key Unannounced Inspection 26th September 2006 3:00 Mellor House DS0000015510.V313264.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 Mellor House DS0000015510.V313264.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. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 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) www.mencap.org.uk Royal Mencap Society Manager post vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 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. The monthly fees, range from £1031. 39 to £1082.71 per week. There are eight spacious single bedrooms with hand washing 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.V313264.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Upon arrival the home felt homely, welcoming, clean and service users looked relaxed and happy. Staff were observed to be fully engaged in appropriate activities with the service users. The inspection took place over 5.5 hours, a relative, staff and service users were spoken with. Some time was spent looking through necessary paperwork to assess whether any improvements had been made since the last inspection in May 2006. What the service does well: What has improved since the last inspection? Nineteen of the nineteen requirements from the last inspection were in the process of either being completed or had been fully completed. This is a good achievement. The manager has had a difficult task of identifying service users personal wishes and goals due to their disability and difficulty in making their needs understood, however she has spent 1-1 time with each individual sharing relevant information with them and developing communication aids which support service users to make choices. Photographic evidence of daily activities are now in place for each service user. There are permanent and agency staff pictures on the walls to identify the staff team and allow service users to know who is on shift for that day, also it allows service users to make a choice of who they would like to work with them for specific activities. The home has introduced a personal care planning system, which has now been fully implemented, the information provided is clear, informative and inclusive of service users individualised preferences and needs. All service users and parents have been able to take part. Staff on duty during the day were spoken with on this inspection. Positive comments were expressed regarding the working conditions. Training opportunities are good, supervision, staff meetings, hand overs and relationships with families have improved and are regular. New staff have been recruited and agency staff are being used less. The garden has had a make over and looks smart, appealing and adds to the homes overall appearance. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. Mellor House demonstrated that it has procedures, which meets the needs of individuals prior to admission. EVIDENCE: Pre-admission and initial assessments were evidenced in resident’s files. Yearly reviews of service users have gone ahead and relatives spoken with confirmed this to be the case and that the reviews were in depth. A new statement of purpose has been written, which includes Staff training and qualifications and complaints procedure. Care plans have been based on person centred planning and have been recently reviewed and were evidenced as being written and recorded from the services users needs, likes and dislikes. Policies and procedures are in place regarding pre admission activity such as a prospective service user visiting the home and assessments to be carried out prior to them moving in. There have been no new service users admitted recently. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The home has demonstrated that a new care plan process for all service users is in place and that a good system of risk assessing is in place. Care plans are to a good standard and evidenced other professionals have been used whilst gathering or reviewing care plans. EVIDENCE: All new care plans had been put into action. The care plans have been written from service users points of view as much as possible. The care plans have included the involvement of families, staff observation, day centres and other professionals. There has been involvement of residents, families and advocates. Relatives confirmed that consultation has gone ahead that this is evidenced and recorded. The care plan itself has a ‘holistic’ approach and covered all areas of a person’s life which you would hope to be included such as preferences, safety, communication, spiritual, education and what individuals could/could not or should be encouraged to do. There was a greater emphasis on recording observations of what individuals liked and disliked and what may work or what may not be that person’s preference. Risk assessments were in place and it was good to see that risks corresponded with the care plan inspected. Risk assessments in general were of a good standard and reviews of risks were dated or booked in to be reviewed. Risk assessments also identified why some risk taking could be positive to the Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 10 individual and included control methods/guidance on reducing high risks to a safe acceptable level. All risk assessments were recorded appropriately, signed for and dated. There has been an improvement in involving residents in information sharing. The home maintains policies and procedures regarding confidentiality and this issue forms part of the induction process Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15,16 & 17 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The home has improved service users involvement within the community and the new care plans allow greater involvement of service users and families. Relationships with resident’s families in general have improved. Overall interaction and involvement in the service users lives has improved. EVIDENCE: All service users are engaged in day services every day of the week. This gives service users the chance to mix with their own peer group. Some service users use the evening clubs to socialise. There was evidence through activity, paperwork and staff spoken with on the day of inspection that there had been improvements of involving service users within the community. The manager has developed the use of photographs that are dated and have reference to activities carried out. The manager is also in the process of taking photographs of food to enable service users to have greater choice. New paper work implemented explores activities tried with individuals and looks at who was involved, why, if it didn’t work why and if it is a activity the service users likes is incorporated within the weekly activity rota. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 12 Service user meals were observed. It was noted that staff sat with service users and passed the time of day with them. Meals provided were nutritious. A clearer daily record of the diet for all individuals within the home needs to be maintained on a regular basis. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 13 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 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. Service users personal and healthcare support is well managed and written information was evidenced. Paperwork within the home is being maintained to an appropriate standard. Medication systems are in place. EVIDENCE: There has been a new care plan format developed and this addresses individuals needs in terms of personal, physical and emotional health needs better, these have now been fully implemented for all service users within the home. All service user reviews have been completed apart from two who are under Essex County Council and the home is still waiting for Essex to rearrange dates the home had set for reviews and they could not attend. No serviced users retain their own medication due to their level of disability. The medicine cabinet needs to be raised from its current position as it is sited too low on the floor. This presents a health and safety issue regarding manual handling for the staff administering medication. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 14 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 & 23 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The current manager of the home is working closely with families on a one to one consultation basis. Staff are having regular supervision and regular staff meetings. EVIDENCE: Relatives spoken with knew about the complaints procedure and how to complain and have used this procedure. A relative spoken with felt that there was a general improvement in that relatives meetings are more regular and they felt that the manager and staff are approachable for 1-1 issues or any concerns. All complaints information is up to date. No complaints have been made to the CSCI since the last inspection. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The home in general is clean and hygienic with no apparent odours. Service users bedrooms provided a good amount of space and individuals had specialised equipment if needed. EVIDENCE: The home provides a high quality of shared spaces and individual rooms. The kitchen has recently been refurbished. However staff must regularly and consistently make sure that all food within the fridges is labelled appropriately and that the fridge is cleaned regularly. All service users bedrooms are nicely decorated and maintained to a good standard. The laundry room had been re-organised and shelving was repositioned to ensure safety. The manager has got decorating quotes for the hallway, dining room and some service users bedrooms to be re-decorated. The garden has recently had a make over and looks smart, appealing and adds to the homes overall appearance. A small activity area is provided, including a large swing. The home has reviewed that all service users specialist equipment have up to date assessments in place to ensure they have the correct equipment in place. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. Staff spoken with felt that they are supported through the management structure and support from supervision and staff meetings. Training opportunities are good. EVIDENCE: On the day of inspection the manager demonstrated that new staff had been acquired and that these staff included male and female and are from similar cultural and ethnic background as the service users. The rota was maintained and clearly identified that there are enough staff on duty and the times they are to work. Full names of all staff including agency staff are identified. One service users initial assessment identifies that funding for two waking night staff for this individual is needed and this is not being provided. The manager needs to ensure this is discussed with the placing authority that funds this individual. Training opportunities are good. Courses to be undertaken include pressure area care, infection control, moving and handling and very positively, inclusive learning. Staff spoken with reflected that courses undertaken had developed a better understanding of the service users they worked with. The Manager is being proactive in booking numerous courses and then identifying who is to Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 17 attend through the supervision process. Pova training for all staff is now complete and there are plans to include newly recruited staff on this training. The organisation maintains robust recruitment and it was pleasing to note that a major overhaul of staff records had taken place, which included an update for staff on working permits. Of the three recent staff files sampled, all had the required information available. Any photocopies had confirmation that the registered person has seen the original. The Manager maintains good information on agency staff including training, references and CRB checks. An induction checklist is carried out for all agency staff. Currently, staff who have shown great ability, are to be block booked if possible to ensure consistency. Supervisions for staff and staff meetings have been regular. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The manager has made effective changes and has generally improved on written records. EVIDENCE: Quality Assurance has been carried out with all interested parties and the manager is in the process of collating all the information and putting an action plan together. This will be forwarded to the CSCI when completed. The new Acting Manager has the NVQ Registered Managers Award at Level 4 and is working towards the NVQ 4 in Care. She also holds the City and Guilds 3252 in Management in Care. She has worked for 3 years as a deputy or acting Manager and the last three years has been registered Manager at another home. Her position at Mellor House is only temporary for one year – she has been in post since the beginning of April 2006. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 19 The present manager has clearly made a positive impact on the running of the home. Staff and relatives of service users appear more contented with the current situation at the home under her leadership. Health, safety and welfare of service users and staff have been a priority since the new Manager came into post. All health and safety checks inspected were up to date The manager has put into place daily checks that are carried out by her and the two deputies of Mellor house. Service users are benefiting from a strong management team and the level of service is promising to improve. Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 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 2 34 3 35 3 36 X 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 3 3 3 X X X 3 X X 3 X Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA42 Regulation Reg 16 (2) ( g) ( h) Requirement The registered manager must ensure that all food within fridges is labelled appropriately and that the fridge is cleaned regularly. Timescale for action 30/11/06 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 2 Refer to Standard YA17 YA20 Good Practice Recommendations Meals provided to individuals need to be accurately reflected in service user records The medical cabinet needs to be at a level so that it ensures the health and safety of staff and reflects the principles around manual handling. The rest of the staff team need to complete training around communication tools, valuing people, equal DS0000015510.V313264.R01.S.doc Version 5.2 Page 22 3 YA35 Mellor House opportunities, disability and race equality 4 YA39 Manager must ensure that when the quality assurance survey is collated and action plans have been identified this is forwarded to the CSCI office. New staff continue to complete an induction and foundation training package. 5 YA42 Mellor House DS0000015510.V313264.R01.S.doc Version 5.2 Page 23 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. 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