Inspection on 08/12/05 for Mercers

This inspection was carried out on 8th December 2005.

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

Mercers 27/09/07

Mercers 11/10/06

Mercers 15/03/06

Mercers 26/01/05

Mercers 03/08/04

Mercers 03/03/04

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 Mercers 14 Serpentine Walk Colchester Essex CO1 1XR Lead Inspector Neal Wolton-Harragan Final Unannounced Inspection 8th December 10:00 Mercers DS0000028660.V272064.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 Mercers DS0000028660.V272064.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. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mercers Address 14 Serpentine Walk Colchester Essex CO1 1XR 01206 570226 01206 570226 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) Mr Pelandapatirage Gemunu Susantha Dias Mr Gary John Kittle, Mrs Kaushali N Kittle Mrs Kaushali N Kittle Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 6 persons of either sex, aged 65 or under, who only fall within the category of Learning Disability 26th January 2005 Date of last inspection Brief Description of the Service: Mercers offers accommodation and care for up to six individuals, with learning disabilities, between the ages of 20 and 40. Registered in 2002, the home is owned by Mr P Dias and Mr and Mrs Kittle, with Mrs Kittle as Registered Manager. All three proprietors are qualified nurses. The premises consist of a two storey, detached property in a residential area within walking distance of Colchester town centre. All bedrooms are single occupancy, two of which are on the ground floor. One of the ground floor rooms, a recent addition off the conservatory, has en suite facilities, although none of the older rooms have such facilities. Communal facilities include a lounge, dining room and conservatory, which had been extended shortly before the inspection. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection at Mercers, the first inspection of the home for the 2006-2006 inspection year. Mrs Kaushali Kittle, the home’s Registered Manager was not at Mercers on the day of inspection, but her Assistant Manager, Carol Sweeney, was available throughout the visit and contributed fully to the inspection process. During this inspection, 32 of the 43 applicable standards were looked at; 30 were met and two were nearly met. During the day of inspection, three members of staff were spoken with, as well as four service users and one visiting relative. The visitor, staff and service users spoke well of the home and of its management, service users appeared at ease with the care staff and were happy to talk to the Inspector. Interactions between staff and service users, observed during this inspection, were positive. This inspection included discussions with service users, staff and the home’s Manager, as well as the opportunity to look at records of how people living at Mercers were supported and how the staff were recruited and trained. What the service does well: What has improved since the last inspection? Since the last inspection, there has been a marked improvement in the way staff working at Mercers are supervised and supported. Records showed that care staff were now having regular individual meetings with their manager to monitor their work and to help them identify their training needs. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 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. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 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 Mercers DS0000028660.V272064.R01.S.doc Version 5.0 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): 1, 2, 4 & 5 Prospective service users had the information they need to make an informed choice about where to live as well as an opportunity to visit the home prior to moving in. Prospective service users’ individual needs were comprehensively assessed prior to entering the home. Service users did not have individual written contracts or statements of terms and conditions with the home. EVIDENCE: The home had an appropriate Statement of Purpose and Service User Guide, which were made available to existing and prospective service users. This information, along with opportunities to visit the home prior to moving in, as well as the homes policy of service users entering the home on a trial basis, supported prospective service users to make an informed choice about where to live. Service user records did not show evidence of each service user having an individual written contract or statement of terms and conditions with the home. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 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, 8 & 9 Service users’ assessed and changing needs were reflected in their individual plans and service users were involved in the decision-making process in all aspects of their lives. Service users were supported to take risks as part of an independent lifestyle. EVIDENCE: The service user records, sampled during the inspection, showed that individual needs were assessed and were reflected within individual service user plans. These plans were subject to regular monitoring and review and changes in needs were identified and acted upon. The examination of records and discussions with individual service users gave evidence that service users were central to the decision-making processes within the home, as well as playing a primary role within the care review system in place. Records showed that comprehensive risk assessment had been undertaken and risks were managed and reviewed appropriately. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 10 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 & 17 Service users had opportunities for personal development and were able to take part in age, peer and culturally appropriate activities. Service users were active members of the local community, engaged in appropriate leisure activities and had appropriate personal, family and sexual relationships. Service users’ rights were respected and responsibilities recognised in their daily lives. Service users were offered a healthy diet and enjoyed their meals and mealtimes. EVIDENCE: Examined service user records gave evidence that each person living at the home had a detailed weekly programme that included work, education and leisure type activities. Service users spoken with on the day of inspection stated that they used community facilities as part of their daily lives and enjoyed the activities on offer. Discussion with service users and staff, as well as the examination of records, showed that service users’ rights were respected and appropriate personal Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 11 relationships supported. All service users had keys to their own rooms and some chose to keep their doors locked. Discussions with service users and the examination of records showed that a varied diet was offered to service users with all nutritional needs being met. Service users stated that the weekly menu was compiled jointly and that those living at the home participated in the shopping and meal preparation. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 12 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. Service users received personal support in the way they preferred and required. Physical and emotional health needs are met. No service users retained, administered or controlled their own medication at the time of this inspection. Service users were protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Service users spoken with were happy with the way they were supported at Mercers and this was reflected within the care plans examined. Care plans identified individual needs, as well as the choices made by individuals as to how these needs were to be met. Care plans were well detailed, regularly monitored and formally reviewed at appropriate intervals, depending on individual need. There was an ongoing process of assessment to take account of the changing needs of individuals and the services of healthcare professionals, such as community nurses, speech and language therapists or psychologists, were accessed as necessary. None of the service users retained, administered or controlled their own medications at the time of this inspection, although some service users spoken with understood the nature of their medications and why these had been prescribed. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 13 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 Arrangements were in place to help protect service users from abuse, neglect and self-harm and service users felt their views were listened to and acted upon. EVIDENCE: The home had a robust complaints procedure. The adult protection policies and procedures were adequate to protect service users from abuse and where service users presented with behaviours likely to cause self-harm these behaviours were identified within their care plans and management strategies devised. Service users spoken with on the day of inspection expressed the belief that should they have concerns or complaints these would be taken seriously by the staff and manager of Mercers and appropriate actions would be taken. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 14 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 Mercers was a homely, comfortable and safe environment for service users and all areas were clean and hygienic. EVIDENCE: Although not all areas of the home were subjected to scrutiny at this inspection, those areas visited were seen to be homely, comfortable and safe. Service users expressed satisfaction with their environment both inside and out. All areas visited on the day of inspection were clean and hygienic. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 15 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 & 36 Service users benefited from clear staff roles and staff were appropriately trained to meet the individual and joint needs of service users. Competent and qualified staff supported service users and staff were adequately supported and supervised. Service users were not always protected by the homes recruitment policies and practices. EVIDENCE: Examination of staff records, as well as discussions with the Registered Manager and staff, gave evidence that care staff had a good understanding of their roles and responsibilities and that staff were qualified and competent. Staff were employed in sufficient numbers to meet the needs of the service users, creating an effective staff team. Staff spoken with on the day of inspection stated that training was regularly made available and the home’s Manager fully supported staff in meeting their training needs. However, one staff file showed that the CRB disclosure and references that Mercers had for one member of the care team had been sought by the carer’s previous employer and not by this home. The registered person must ensure that all pre-employment checks are undertaken and appropriate documentation maintained. Discussions with carers and examination of records showed that a system of regular support and supervision for staff was in place and records were maintained accordingly. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 16 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 & 42 The home was well run, with a positive ethos. The leadership and management approach of the home was good and service users’ views were central to the home’s quality assurance processes. The home promoted and protected the health, safety and welfare of service users, staff and visitors. EVIDENCE: Examination of records, discussions with staff and discussions with service users and gave evidence that the home was well managed. Mrs Kittle, the Registered Manager, has appropriate skills, qualifications and experience and supports the development of skills within the team members. Mrs Kittle was away from the home on the day of inspection, but this did not appear to affect the running of the home as all staff were fully equipped to continue in her absence, under the guidance of Carol Sweeney, the homes Assistant Manager. Ms Sweeney informed the Inspector that she was due to commence an NVQ level 4 award in January 2006. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 17 The home had regular service user meetings and these were central to the quality assurance process. Records examined showed that the health, safety and welfare of service users, staff and visitors was protected and promoted. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 18 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 3 3 X 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mercers Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 3 X DS0000028660.V272064.R01.S.doc Version 5.0 Page 19 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 YA34 Regulation 19 Schedule 2 Requirement The registered person must ensure that all pre-employment checks are undertaken and appropriate documentation maintained. Timescale for action 05/02/06 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 Refer to Standard YA5 Good Practice Recommendations It is recommended that copies of terms and conditions of residence, issued to service users, be retained in individual service user records for future reference. Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Mercers DS0000028660.V272064.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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