Inspection on 08/08/07 for Menna House

This inspection was carried out on 8th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Menna House 31/07/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Menna House Menna Grampound Road Truro Cornwall TR2 4HA Lead Inspector Lynda Kirtland Unannounced Inspection 8th August 2007 9:15 Menna House DS0000069008.V344282.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 Menna House DS0000069008.V344282.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. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Menna House Address Menna Grampound Road Truro Cornwall TR2 4HA 01326 371000 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) Spectrum Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 5. Date of last inspection New Service – first inspection Brief Description of the Service: Menna House is a care home providing accommodation and care for up to five adults, of either gender, with a learning disability. The registered provider is Spectrum, an organisation that provides specialist services for people with Autistic Spectrum disorders. Menna House opened in March 2007 and is being set up as a home where service users who already have a reasonable level of independence can continue to develop their personal and social skills. Spectrum currently employs an acting manager and a team of staff to run the home on a day-to-day basis. External, on-call managers are available to provide specialist input, support and advice where necessary. The home is located in the village of Menna ten miles from the city of Truro. The home has a vehicle to provide transport for service users who need to access resources in the wider community. The home is a two-storey building. All the bedrooms have en suite bathroom facilities. The bedrooms are on the first floor. Service users must be able to negotiate stairs. There are good facilities for staff sleeping in and the home has a dedicated office on the ground floor and in the loft space. The home has two lounge areas, separate dining area, family room and extensive gardens, which includes a vegetable plot for service users use. The garden is securely fenced. The home has some parking space at the front of the building. There is a communal kitchen and ample storage space in the home. Laundry facilities are located in a separate area to the kitchen. The manager stated that the current range of fees is from £932.19 to £2833.56 per week. Service users are responsible for purchasing personal items such as toiletries. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Menna house opened in March 2007 and this was the first unannounced key inspection, which took place on 8 August 2007 and lasted for approximately seven hours. The purpose of the inspection was to ensure that service users’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that service users’ placements in the home result in good outcomes for them. Information received from and about the home since its opening has also been taken into consideration in making judgements about the quality of outcomes for the service users living there. The inspection included meeting with all five of the service users (residents) currently living at Menna House. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the acting manager. We talked to five people using the service, and asked staff about those people’s needs. We also looked at the care plans, medical records and daily notes for these five people. This is called case tracking. Two residents were case tracked in detail at this inspection. There were opportunities to directly observe aspects of residents’ daily lives in the home and staff interaction with them. What the service does well: Four out of the five residents lived together in a previous care home and therefore knew each other well before moving into Menna House. It was evident from looking at documentation, talking with residents, written compliments from relatives and a tour of the home by two residents that there was a planned moving in period to Menna House. Residents said that they choose the décor of their rooms and communal areas and showed photos of their planned move to Menna House. All residents demonstrated or said that they ‘liked’ Menna House. Menna house had a open day and some written comments from relatives regarding the home were: “what a beautiful place to live and I am so impressed by the way the residents have decorated their bedrooms”: “everyone seems so happy and content…. its just like one big happy family a really nice home”. Residents were each provided with written and pictorial information about the home. The home operates like a shared domestic dwelling with staff support provided where it is needed to assist them to develop and maintain their skills and independence. One resident said “I like it here”. Assessments prior to moving into Menna House are undertaken and based on the individuals health, social and personal care needs, including needs relating Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 6 to their religious, ethnic and cultural backgrounds, to ensure they can be met in the homes setting. Residents are encouraged and supported to develop their skills and independence in many ways. They are involved in developing their own care plans with assistance and support from staff. Residents attend reviews regularly, so that they know why they are placed at the home and via their person centred planning (PCP) process identify what aspirations they are aiming to achieve e.g. developing a particular element of self-care to promote their skills and independence. They have opportunities to make decisions about important aspects of their lives, with assistance from staff, if they need it and are supported to take risks so that they can enjoy fuller and more active lives in and out of the home. Menna house have introduced a monthly photo dairy that is produced by the residents and staff. This clearly evidences what activities the resident has completed on a daily bases and a copy of this is sent to residents parents/ representatives. One parent wrote: “we were pleased to have the monthly diaries about …… it is great to know how …. spends her time – a excellent idea.” Residents have clear information on what is expected of them and their rights as residents of a care home. They are aware, for example, that they will be expected to help out with household tasks such as cooking and cleaning, so that they can develop their skills and independence and know what to do if they wish to make a formal complaint about something they do not like. Residents participate in the planning of the menus and help staff to prepare meals. They have free access to the kitchen so that they can make drinks and snacks for themselves when they wish and are encouraged to live and eat healthily. Residents are appropriately supported with their personal care so that they maintain their dignity. Staff were observed to assist them with their needs quietly and unobtrusively. Menna house has been refurbished throughout. Residents played a big part in the choosing of the décor and furnishings in the home, which are to a high standard. The home’s environment is suitable for the residents living there. It was clean and tidy throughout at the time of the unannounced inspection. The staff team demonstrated throughout the inspection positive interactions with residents and assisted them with personal care needs in a discrete manner. Newly appointed staff confirmed they had a comprehensive and valuable induction to Spectrum. Staff confirmed access to training is available. The inspector was welcomed to the home in a friendly manner by staff and residents. All were aware of the reason of the inspection. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: As this is the first inspection a number of statutory requirements and recommendations were identified to further improve the service that Menna House provides. The following statutory requirements were identified: During the inspection of medication it was noted that since opening the home there has been a minimum of 4 medication errors of which the Commission was only made aware of one. The manager was made aware of the Regulation 37 procedure and what other events needed to be reported to the commission and to ensure this occurs in the future. The medication errors were in relation to medication not been administered, and MAR sheets completed inaccurately. The MAR sheets must be completed as medication is administered. It was difficult to undertake an audit of medicines, as the MAR sheets did not record the number of tablets it had received and therefore a tablet count was difficult to do. The manager stated that some staff had completed in house medication training. It is essential all staff complete accredited medication training. The homes statement of purpose identifies that there will be a minimum of three staff on duty during the day and two in the evening. The manager stated, confirmed by rotas that during the transition period, and summer holidays that staffing levels have increased to 5 staff on shift during the day and four in the evening. Concern was raised as to how the staff team would be able to meet individual’s needs as specified in their care plans and risk assessments, if staffing levels dropped to the minimum levels as recorded in the statement of purpose as this would restrict residents accessibility to activities etc. Therefore these numbers must be reviewed taking into account residents individual and group risk assessments to ensure there is sufficient competent staff on duty at all times. The homes manager is aware that staff need to attend specific training courses to assist them in their daily work and is arranging for them to attend such courses i.e. medication, infection control, health and safety, manual handling, infection control, food hygiene and positive behavioural management. Annabelle Verris the current manager has been in post for 3 months. It is of concern that Spectrum changed the management of the home so quickly after opening and not applied to the Commission for registration. Ms Verris said she is completing her application and will forward it to the commission. Ms Verris confirmed she aims to complete her NVQ level 4 by October 2007. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 8 It was observed that some doors were wedged open, this poses a health and safety risks especially in the event if a fire and should not occur. The following recommendations to further develop the quality of care that Menna house aims to provide were identified: • Care plans are reviewed monthly and it is recommended that the staff record resident’s views in this process: • To assist with medication guidelines it is recommended that a copy of the Royal pharmaceutical guidelines be gained. • The home has had a water leek that has damaged the décor in the hallway this should be repaired. • The acting manager has requested window restrictors be fitted on first floor windows and this will be monitored. • The manager has completed an environmental risk assessment and from this she has identified that the gateway needs to be moved closer to the home so that access is safer for residents. This should be completed • The Manager should attend the Multi Disciplinary Adult Protection training. • As this is a new build staff lockers should be provided for them to store their belongings. • The staff team are below the national minimum standard of 50 qualified at minimum of NVQ level 2. The manager said this is being addressed. • Staff do not have copies of the General Social Care Councils Code of practice and these should be gained. The inspector would like to thank residents, staff and acting Manager for their cooperation and assistance throughout this inspection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 9 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 Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed prior to their admission so that they can be confident it will meet their health, personal and social care needs, including needs relating to their age, religion, cultural and ethnic backgrounds, abilities, gender and sexual orientation. EVIDENCE: From observations and talking with residents it was evident that they are settled in the home, and that they get on well with each other and with the staff. A copy of the home’s statement of purpose and Service Users Guide is placed on the individuals file. This is presented in written and pictorial formats. From documentation inspected it was evident that admissions are made following a full assessment and in consultation with the resident, their family or advocate, and relevant professionals. Transitional work for the service user moving into the home was undertaken in a planned manner and at the residents pace. A resident’s representative commented, “ the transition seems to have gone very smoothly.” Contracts in relation to the placement clearly identify residents’ rights and what services they will be provide with. It also identifies if there are costs that the resident needs to pay and identifies their benefit entitlements. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are aware of their care plans, which fully address their health, personal and social care needs, including needs relating to their individual and diverse backgrounds (age, religion, culture and ethnicity, abilities, gender and sexual orientation). They are able to take safely managed risks and make important decisions about their lives so that they develop their skills and independence. EVIDENCE: Residents, their family, advocate and relevant professionals are involved in the development of individual care plans and their subsequent reviews. Monthly reviews are held and it is recommended that the staff record resident’s views so that they are aware of the purpose of their placements in the home and are able to contribute to the ongoing care planning process. The care plan has specific headings to address their health, personal and social care needs, including their individual and diverse needs. These are in written form plus in Widget (pictorial) form. Care plans provide residents with specific goals to work towards, and inform and direct staff in how to support the resident to achieve this goal to encourage them to fully maximise their skills for Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 12 independent living. As the care plan documentation can be lengthy the introduction of ‘micro care plans’ summaries particular aspects of care and details what specific staff interaction is needed are now available. Residents participate in making decisions about important aspects of their daily lives, according to their individual abilities and this was observed during the inspection. Staff were observed supporting residents who required it, to make decisions about what to do during the day. Residents written care plans formally consider their abilities to make decisions for themselves and daily care records provide further evidence of the choices they make in their daily lives. Residents can choose the level of privacy they wish to enjoy in their private accommodation. Residents are able to take managed risks, backed up with written risk assessments and risk management plans, particularly with regard to their engagement in higher risk activities. Resident’s monies are audited on a monthly base at Spectrum headquarters. They were not inspected on this occasion. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in a wide range of activities in and out of the home, which are appropriate to their ages, individual needs, interests and cultural backgrounds so that they develop their skills and confidence. They are supported to maintain valued social and family relationships so that they are not isolated or institutionalised. They are informed of their rights and responsibilities so that they are aware of what is expected of them. They are provided with a wholesome and varied diet so that they enjoy their meals and stay healthy. EVIDENCE: Residents care plans and daily care records provide good evidence that their interests and abilities are fully considered in planning their daily activities, which are planned with them individually. This is then displayed in either word or widget formation as a “daily activity rota” so that residents can follow their routine more easily. Some activities include assisting them to access voluntary employment opportunities, college, involved in variety of sports, going for Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 14 walks and pub lunches for example. A monthly photo dairy that is procduced by residents and staff demonstrate the level and range of activities that a resident participates in. This has received positive feedback from relatives. At the time of the inspection residents were engaged in a variety of different and appropriate activities in and out of the home, with staff support provided as necessary. In addition residents daily care records show that they access a wide range of community resources with staff support, depending on their individual needs and abilities. Residents are encouraged to maintain valued relationships with their families and friends, with staff support as necessary, which their daily care records confirmed. They are able to make telephone calls in private if they wish Residents are supported and encouraged to eat healthily. They undertake shopping, planning for and preparing meals with assistance from staff. In addition residents have a rota for washing up, drying up, setting the table or having a night off. Nutritional needs and preferences are considered as part of the care planning process. Resident’s views are sought in the weekly menu planning. All the residents looked healthy and well nourished. The home has an ordinary, domestic kitchen, which they can access freely, to prepare drinks and snacks when they want them. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. Medication systems need to improve to ensure that medication errors are prevented. EVIDENCE: Residents individual care plans address their personal care needs. Residents appeared to be attractively and fashionably dressed and were well groomed so that they can comfortably take part in community life. The home has suitable bathroom facilities so that they can attend to their personal care in private. Resident’s healthcare needs are considered as part of the care planning process and regularly reviewed. Residents confirmed by documentation showed that they access external healthcare providers, including specialists, when they need to. There are suitable medication storage facilities. Residents do not currently selfadminister medication. Spectrum has a medication policy that was present in the home. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 16 From inspecting incident sheets it was noted that since opening the home there has been a minimum of 4 medication errors of which the Commission was only made aware of one. The manager said she was unaware of the Regulation 37 procedure and what other events needed to be reported to the commission. This was explained and she said she would ensure this occurs in the future. The medication errors were in relation to medication not been administered, MAR sheets were signed to state medication had been administered but it had not, on another occasion medication was found in a cup. The MAR sheets must be completed as medication is administered. It was difficult to undertake an audit of medicines as the MAR sheets did not record the number of tablets it had received and therefore a tablet count of tablets, which were not in blister packs, was difficult to do. It is required that improvements in this area are made. It is of concern that when PRN medication is to be administered outside of 9-5 hours that the manager on call is asked to authorise this. This manager may not know the resident, as they do not manage that particular home for example. Spectrum needs to review if this system is appropriate. Due to this and the concerns around medication errors in Spectrum homes the Commission will discuss with Spectrum management team the quality of the medication training for staff and its accreditation. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home. EVIDENCE: Residents were encouraged to speak to the inspector if they wished in private or with staff present so that they could make their views known or raise any concerns. No concerns were raised. Residents are provided with written copies of the home’s formal complaints procedure and have formal and informal opportunities to raise any concerns with staff before they become serious complaints. The home has received 18 compliments from family members and professionals since opening and no complaints. The home has written procedures to guide staff on what to do if they suspect a resident is at risk of abuse. There are records to show that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and appropriate checks are made. Residents are not isolated in the home, but take part in a range of activities in the local community and have relationships with people from outside of the home that they can communicate serious concerns to. Spectrum has a whistle blowing policy. It is recommended that the acting manager attend the Multi Disciplinary Adult Protection course. The home does have a copy of the Cornwall Multi agency adult protection procedure. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment provides service users with an ordinary, domestic setting so that they can develop their skills and independence in a noninstitutional setting. Consultation with Service users has led to communal and private space being furnished to a comfortable and high standard. It is safe and clean so that service users are protected from risks of cross-infection. EVIDENCE: Two residents showed the inspector around the home. The home looks like an ordinary, domestic dwelling. Residents expressed that they are pleased with the furnishings and décor of the home. They were particularly pleased with their en suite bedrooms that they had personalised and the communal lounge areas, which were attractively furnished. The home has had a water leek that has damaged the décor in the hallway this should be repaired. The acting manager has requested window restrictors be fitted on first floor windows. She has completed an environmental risk Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 19 assessment and from this she has identified that the gateway needs to be moved closer to the home so that access is safer for residents. Staff were aware of COSHH and relevant lockable storage was in place to store these items. The home appeared clean and tidy throughout at the time of the inspection, which was unannounced. The acting manager is aware that staff need to attend infection control course of which some are booked to attend. Staff have good sleeping in facilities. As this is a new build lockers should be provided for them to store their belongings. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 . Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Currently there are sufficient numbers of staff on duty so that service users can have confidence in their competence and skills; it would be of concern if this level dropped and therefore should be reviewed. Staff training needs to be reviewed and any gaps in training identified and addressed. The home’s recruitment policies and practices are fair, safe and effective so that service users can be assured that staff are suitable to work in a care setting. Staff receive regular, formal supervision. EVIDENCE: The homes statement of purpose identifies that there will be a minimum of three staff on duty during the day and two in the evening. The manager stated, confirmed by rotas that during the transition period, and summer holidays that staffing levels have increased to 5 staff on shift during the day and four in the evening. Concern was raised as to how the staff team would be able to meet individual’s needs as specified in their care plans and risk assessments, if staffing levels dropped to the minimum levels as recorded in the statement of purpose as this would restrict residents accessibility to activities etc. Therefore these numbers need to be reviewed. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 21 Care staff undertakes all personal care duties plus with residents assistance cleaning and cooking tasks. At night one member of staff sleeps in and one waking night is on duty. The staff team have been consistent since the opening of the home, with support from a couple of bank workers due to staff long term sickness at the home. From observations of staff interaction with residents it was evident that they communicate with residents in a competent, fair, patient manner and work with them at their pace. Staff commented that they enjoy working at Menna house with the current resident group, feel they work together well as a team and that they have good management support. The homes manager has arranged for staff to commence the NVQ level 2 training. Currently only one member of staff has NVQ level 3, with another member nearing completion of the same course. Therefore the staff team are below the national minimum standard of 50 qualified at minimum of NVQ level 2. The homes manager is aware that staff need to attend specific training courses to assist them in their daily work and is arranging for them to attend such courses i.e. medication, infection control, health and safety, manual handling, infection control, food hygiene and positive behavioural management. The home’s staff recruitment records indicate that staff are appointed on the basis of written application forms and equal opportunities interviews. Appropriate checks are made of their suitability to work with vulnerable adults in a care setting. It was noted that residents are not currently involved in the recruitment process but newly appointed staff felt that residents views were being sought during their probationary period of work. Staff do not have copies of the General Social Care Councils Code of practice and these should be gained. Staff, confirmed by documentation, stated that there is regular formal supervision. Staff found this to be beneficial. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The homes manager must apply to the Commission to be registered so that an assessment of her fitness to provide this role is assessed. The home is mainly well managed for the benefit of service users. There are formal and informal systems in place to ensure that service users’ views are accounted for in the day-to-day running and ongoing development of the home. There are systems in place to protect service users from avoidable harm and injury. EVIDENCE: Annabelle Verris the current manager has been in post for 3 months. It is of concern that Spectrum changed the management of the home so quickly after opening and not applied to the Commission for registration. Ms Verris said she is completing her application and will forward it to the commission. Mr Burridge, Spectrums deputy director/compliance officer, who was undertaking a regulation 26 visit during the inspection, will forward details to the Commission of Ms Verris qualifications and experience to demonstrate that she Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 23 is fit for purpose to manage the home. Ms Verris confirmed she aims to complete her NVQ level 4 by October 2007. Staff spoke highly of Ms Verris skills and felt that she was approachable and listened to their ideas or concerns. From observations residents communicated with her in a relaxed manner. Ms Verris has one day dedicated administration time. As the service is new a quality assurance process has not commenced However views from residents, family and staff plus regulation 26 visits have been sought as the home is in the early stages of its development. Records are stored confidentially, staff need to be conscious of their recordings to ensure that it adheres to the data protection act i.e. communications book. The home’s environment appeared safe and there are written individual and environmental risk assessments in place to minimise risks to residents and staff working in the home. Maintenance of the home and its equipment and inspections undertaken by Environmental health are all satisfactory. The home’s fire safety records were completed and up-to-date. There are records of regular tests and checks of safety equipment and procedures in the home to ensure service users’ safety. Spectrum employed an independent fire assessor to review the homes fire risk assessment in line with the new legislation. Fire doors on the ground floor are wired into the alarm system and so close automatically. However upstairs they are on self-closures and it was noted that some doors were wedged open, this poses a health and safety risk. Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 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 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X X X 3 2 X Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Staff must undergo accredited training in the safe handling of medicines so that service users are better protected from medication errors. MAR sheets must be completed when medication is administered to evidence accountability for the administration of medication. All events notifable under regulation 37 of the care Standards Act 2000 must be reported to the Commission The minimum staffing levels must be reviewed taking into account Service users individual care needs and risk assessments both in the home and in the community. These findings should be sent to the Commission. Staff must be provided with essential training so that they are safe to work with service users, with particular reference to training in infection control, food hygiene, medication and DS0000069008.V344282.R01.S.doc Timescale for action 30/12/07 2 YA20 13 (2) 09/08/07 3 YA42 37 09/08/07 4 YA33 18(1)(a)(b) 30/12/07 5 YA20 YA35 18(1)(c) 13(2) 30/12/07 Menna House Version 5.2 Page 26 POVA. 6 YA37 8(1)(2) The homes manager application for the registered manager post must be sent to the Commission without delay. 23(4)(a)(b)(c) Some doors were wedged open, this poses a health and safety risk and should not occur. 30/09/07 7 YA42 09/08/07 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 3 4 Refer to Standard YA6 YA20 YA24 YA24 Good Practice Recommendations Care plans are reviewed monthly and it is recommended that the staff record resident’s views in this process A copy of the Royal pharmaceutical guidelines is gained. The home has had a water leak that has damaged the décor in the hallway this should be repaired The homes environmental risk assessment identified that the gateway needs to be moved closer to the home so that access is safer for residents. This should be reviewed. As this is a new build lockers should be provided for them to store their belongings Staff and managers should undergo multi-agency training in the protection of vulnerable adults from abuse to enhance their knowledge and skills of working together with key agencies involved in this. This is re notified to you. 50 of the staff team should be qualified at minimum of NVQ level 2. Staff should have copies of the general Social care Councils Code of Practice. 5 6 YA33 YA23 7 8 YA32 YA34 Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Menna House DS0000069008.V344282.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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