Inspection on 18/10/06 for Merryfield

This inspection was carried out on 18th October 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Merryfield 29/06/07

Merryfield 07/03/06

Merryfield 26/09/05

Merryfield 03/03/05

Merryfield 07/09/04

Merryfield 06/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Merryfield 20 Merryfield Close Damson Wood Solihull West Midlands B92 9PW Lead Inspector Julie Preston Key Unannounced Inspection 18th October 2006 10:30 Merryfield DS0000004526.V314649.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 Merryfield DS0000004526.V314649.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. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Merryfield Address 20 Merryfield Close Damson Wood Solihull West Midlands B92 9PW 0121 711 7274 0121 7117274 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) Damson Care Mrs Susan Sheldon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th March 2006 Brief Description of the Service: The service at 20 Merryfield Close is provided in a domestic three bedroomed house in a residential area of Solihull. It is registered to provide care, support and accommodation to three adults with learning disabilities. The current service users are three men. There are no aids or adaptations in the home, as they are not required to meet the needs of the service user group. Information is shared with service users via house meetings, which take place on a regular basis. Local facilities and amenities are within walking distance of the home, with the main shopping areas of Shirley and Solihull also within reasonable distance by bus. Staffing is provided by a small staff team, with sleeping-in provision. The fees charged to service users range from £750 to £1400 per week, of which contributions are made according to individuals benefit entitlement. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This fieldwork was unannounced and took place over one day and was the home’s first key inspection for the year 2006 to 2007. Service users were spoken to about what it is like to live in the home. The registered provider and registered manager were present at this visit and answered questions about the running and management of the home. A tour of the premises took place. Care, staff and health and safety records were looked at. Time was spent observing care practices, interactions and support from staff. There were no immediate requirements as a result of this visit. What the service does well: Service users are included in the running of the home, the review of their care plans and are helped to be as independent as possible. Service users make decisions about their lives and receive good support from staff to do so. Lots of activities take place, which service users have chosen and enjoy doing to enable them to have a fulfilling lifestyle. Service users are supported to keep in touch with their friends and relatives. There are good systems in place to help service users stay healthy and safe. Procedures are in place for service users to make complaints if they have any and service users understand how to raise concerns in the home. The home is well furnished and decorated and is comfortable for service users. Service users like the staff that work in the home and have good relationships with them. Service users said about staff, “they’re great, all of them. I love living here”. “What’s good about here is the staff. They’re my friends”. The home is well managed and promotes the protection and well being of the people who live there. Service users are involved in the recruitment of new staff and their views are listened to as part of this process. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Merryfield DS0000004526.V314649.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 Merryfield DS0000004526.V314649.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): 1, 2, 5 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have accurate information to enable them to make an informed choice whether to live in the home. EVIDENCE: The service users living in the home have done so for over seven years so there have been no new admissions within this period. There was a statement of purpose and basic service user guide available. The statement of purpose needed slight updating to accurately reflect the number, qualifications and experience of staff working in the home so that any prospective service users have accurate information about the home. The service user guide was basic and did not contain information about the services and facilities provided and the fees charged for staying in the home to enable service users to make an informed choice about living there. Some pictures had been used to back up written information, however staff and service users commented that written information was reflective of service users communication needs. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 9 Two service users records were sampled. Both included a contract with Damson Care (who provides the care to service users). The contracts had not been reviewed since 2003 and contained incorrect information about the fees charged and a contact address for the CSCI that was incorrect. Action needs to be taken to make sure service users have accurate information about their stay in the home. There was no assessment tool for the admission of potential service users who may wish to live in the home. This must be developed so that potential service users can be confident that their individual needs can be met within the home before they move in. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 10 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good system in place for care planning and risk assessment that involves consultation with service users to enable individual needs to be met and independence promoted. Service users make decisions about their lives and receive good support from staff to do so. EVIDENCE: Two care plans were sampled. Both had been recently reviewed, involving the service user and staff that work with them. Action had been taken to respond to service users’ preferences as part of care plan reviews. For example, a review record stated that a service user no longer wished to access college courses. This was listened to and respected. Alternatives were offered, agreed and provided. Care plan files contained information that had since been reviewed which meant some records no longer reflected service users current needs. It is Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 11 recommended that this be stored separately to the up to date records so that staff, particularly new staff, have accurate information about how to provide support to service users. Care plans that describe service users’ assessed individual needs were seen to be linked to risk assessments that identified controls in place to minimise hazards and promote independence, such as using kitchen equipment safely and eating a healthy diet. Two service users go out alone and use public transport independently. No risk assessment had been completed to describe the way that individuals do this safely. It was reported that the service users had done so for some time and whilst this is appreciated it is necessary that written guidance is put into place to make sure that all staff are aware of any agreed controls for each service user to minimise risks to their personal safety whilst travelling alone. This must be reviewed on a regular basis in accordance with service users individual needs. Monthly reports were observed that had been written by staff and the service user, which recorded service users’ responses to their plans of care. Staff commented that this enabled them to judge whether care plans were effective or needed to be changed to better meet service users needs. Staff were able to clearly describe the support they give to service users which was consistent with the care plans and risk assessments sampled. All service users manage their own money and daily records sampled showed that staff support service users to go out and buy things they want and need. Service users were observed going out to buy personal items at this visit. Service users told the inspector that they have regular house meetings. Records were seen to support this. It was evident from service users comments that issues raised within house meetings had been listened to by staff and action taken to address them. At one meeting service users had discussed their annual holiday and expressed a wish to sometimes “do their own thing” whilst away. Discussion with service users at this visit identified that they had done so and really enjoyed their holiday. Comment cards sent by the CSCI to service users inviting them to have a say about life in the home identified that they all make choices and decisions about their lives and go out when they want to. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 12 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are consulted about their lifestyles and their independence in the home and community is promoted. EVIDENCE: Service users made positive comments about the activities they take part in. “I go to college twice a week, shopping and to the pub. I’m a very busy man”. “I go to work and I love it. I have a pint with my mates after work”. “I like seeing my friends at the club”. The daily records sampled over a seven day period showed that service users went out every day to include such activities as going to the shops, college, bowling, swimming, Birmingham City football club and to visit friends and family members. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 13 At this visit service users went out for lunch and bowling at a near by leisure centre. Service users were asked what they would like to do by staff and agreed these activities as a group. One service user said that he used to go to church, but had decided not to go anymore. This person’s care plan had described this choice and review records showed that the decision was revisited as part of the review process. Care plans sampled included information about the support needed by individuals to keep in touch with their friends and relatives. Two service users commented that they stay with their relatives or receive visits from them at home. There is a pay phone in the entrance hall for service users to contact friends and relatives. Two service users said they had mobile phones, which they really appreciated and had chosen to have. All service users have a key to the front door and their bedrooms. One service user said, “it’s my home so of course I have a key”. Staff spoken to at this visit were very clear that service users bedrooms are private and should not be entered without the permission of the person. Records sampled identified that service users are involved in household tasks, which helps them to develop their independence skills. Service users were observed making hot drinks and snacks, helping with laundry and tidying up the kitchen during this visit. Some service users smoke and it was evident from discussion with them and observation of house meeting records that the rules about smoking had been agreed by the group as a whole to recognise the wishes and well being of non smokers. Menus sampled showed that a range of food is offered consisting of fresh produce and service users “favourites” such as Sunday roasts. Food supplies were observed to be plentiful and all service users commented that they had a choice of meal and were involved in menu planning and food shopping. One service user said he enjoyed peeling the potatoes and vegetables for dinner. The registered manager commented that this was encouraged for the person to maintain and develop his independence. Records of food consumed by individual service users are not kept. These records must be maintained to establish that a well balanced and nutritious diet is offered and received. This is of particular importance for service users with diabetes who are dependent on good diet for their health and well being. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 14 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to meet service users personal and healthcare needs. Medicine management is generally good so that the well being of service users is maintained. EVIDENCE: Staff described service users as having good skills to manage their personal care, which was reflected in the care plans sampled. The assistance needed for each person had been clearly recorded within the plan and reviewed on a regular basis to ensure the information was accurate and consistent with individual needs. Service users stated that they chose their own clothing, used local barbers for haircuts and that the home’s routines were flexible with regard to getting up and going to bed. One service user commented “I go to bed when I want to, it’s my choice”. The home’s staffing rota showed that the majority of staff employed are male, which is reflective of the gender of the service user group. The registered Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 15 manager said she felt that the employment of so many male staff gave service users positive role models within their lives. The home has implemented Health Action Planning for service users. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The plans sampled described how staff should support service users to maintain their health such as the provision of healthy food, regular weight monitoring and attendance at specific healthcare clinics. Service users had signed their plans and told the inspector what they did to stay healthy, such as exercising and avoiding coffee. It was evident that service users were aware of the content of their Health Action Plans and had been consulted about them. Staff at the home had attempted to support service users to give up smoking, by providing information about the risks to health. Where service users had chosen to continue smoking, this had been documented in review records. The health care records sampled showed that service users had visited the GP, dentist, psychologist and chiropodist as necessary and the contact had been documented so that staff were aware both of the reason for the appointment and the outcome. The home provides satisfactory secure storage for service users medicines. Staff have received accredited training in the safe handling of medicines to help them understand the importance of giving out medication safely. Boots supply the medication to the home using the monitored dosage system in blister packs. The Medication Administration records (MAR) cross-referenced with the blister packs indicating that medication had been given as prescribed, except in one case where the noon medication had not been administered to a service user. This was pointed out to the registered manager and addressed during this visit. In one case, correction fluid had been used on the MAR. This is not good practice and must cease. Should recording errors occur, the reasons must be investigated and the outcome clearly documented on the MAR. Written protocols were in place for the administration of PRN (as required) medicines. Staff were able to describe the circumstances under which such medicines should be given. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 16 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are adequate procedures in place for service users and their relatives to make complaints if they have any. There are adequate systems in place to protect service users from harm and abuse. EVIDENCE: There have been no complaints within the home or made to the CSCI within the last twelve months. The comment cards received from service users identified that they knew how to raise concerns and upon discussion with them at this visit it was evident that they were confident that any complaints would be taken seriously and addressed by the staff team. One service user said that if he felt he wasn’t being listened to he would approach a family member but that “I’d never have to”. The registered manager commented that service users’ relatives kept in regular contact with the home and also had access to her mobile telephone number and that of the registered provider in case they wished to discuss any concerns. The home has a complaints procedure, written in plain language accompanied by some descriptive pictures, which service users said they understood. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 17 A copy of the home’s adult protection procedure was observed that included multi agency guidelines from the funding authority which explain how to respond to incidents of disclosed or suspected abuse. Staff at the home have received training in adult protection and demonstrated satisfactory knowledge of how to protect service users. An adult protection issue had been referred to Birmingham Social Care and Health (the funding authority) within the last twelve months, which was fully investigated by them resulting in no further action. The records of this contact showed that the issues had not been substantiated. It was noted from individual care plans that where necessary (in accordance with service users assessed needs) behaviour management guidelines had been developed by psychology services. The guidelines were observed to describe known triggers, which may result in the behaviour occurring and the action that should be taken to avoid the triggers or for staff to respond effectively to safeguard the service user. Records showed that the guidelines had been reviewed in July 2006 and were relevant to the service users needs. Merryfield DS0000004526.V314649.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a pleasant and comfortable home. EVIDENCE: Merryfields is a domestic style property, no different to others in the area, situated in a residential area of Solihull. There is good access to public transport; the nearest bus stop is located at the end of the road, which provides a service to Solihull town centre. This is of particular importance as the home does not provide a vehicle (other than staff using their own cars) to service users to access the community, all of whom use public transport to do so. The home was seen to be clean and warm throughout and furnished to a good standard. The lounge and hallway had been redecorated; service users said they had chosen the colour scheme. The registered manager commented that redecoration had taken place whilst service users were on holiday so that their comfort and safety was not compromised. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 19 There was enough space in the lounge for service users and staff to sit together and a number of photographs, ornaments and pictures were seen which made the room look homely. The home has one combined toilet and bathroom with a shower fitted over the bath on the first floor. The issue of an additional toilet being installed in the house had been discussed with the registered provider at a previous inspection, the outcome being that there is no available space to provide this. Liquid soap was provided in the bathroom, however bars of soap and cotton towels were seen also. It could not be established that the items belonged to or had been used by one person, which presents a risk of cross infection. There home does not have a separate dining room; a table and chairs are provided in the kitchen. Service users said that this was where they ate their meals or sometimes took food into the lounge to eat in front of the television. This arrangement meets the needs of the current service user group. The washing machine is located in the kitchen as there is no space for it to be sited elsewhere. The inspector was advised that there are no continence issues, which could present an infection control risk, and that washing was not handled whilst food was being prepared and eaten to further reduce any risks in this area. Merryfield DS0000004526.V314649.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a well trained and competent team of staff who have good understanding of their individual needs. Recruitment procedures safeguard service users by ensuring only suitable staff are employed. EVIDENCE: The inspector received positive comments from service users about the staff team; “they’re great, all of them. I love living here”. “What’s good about here is the staff. They’re my friends”. It was evident from discussion with staff and observation of their practice that they have built up good relationships with service users and know them well. Staff present at this visit demonstrated knowledge of service users’ needs and the role they played in supporting individuals with their day-to-day lives. The home’s staffing rota was observed that showed male staff are employed, which is reflective of the service users’ gender. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 21 The registered provider stated that service users are involved in the recruitment of new staff by meeting them at interview and talking to potential staff when they visit the home. The recruitment records for one member of staff were sampled. Checks of the person’s suitability to work in the home had been made and the file contained evidence of a satisfactory Criminal Records Bureau check, references, completed application form and proof of identification. Since the last inspection training in Basic Food Hygiene had been provided to staff, as they have responsibility for cooking in the home. The staff training records sampled showed that training had been provided in adult protection, fire safety, safe handling of medicines and diabetes care to enable them to meet service users needs more effectively. It was noted from the supervision records sampled that the process is used to identify staff training needs. Merryfield DS0000004526.V314649.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and promotes the protection and well being of the service users who live there. EVIDENCE: The registered provider and registered manager were both present at this visit. The registered provider is a qualified learning disabilities nurse and has owned the home for over ten years. The registered manager has achieved her Registered Manager’s Award and NVQ Level IV in care. Conversation with the registered provider and registered manager indicated that they are both committed to running the home for the benefit of service users. It was evident throughout this visit that relationships between the manager, service users and staff were very good. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 23 Quality assurance and monitoring is achieved by the outcomes of house meetings, health and safety audits conducted by the registered provider and the home’s own written quality assurance document which was observed to include consultation with service users about their views on living in the home. The records of house meetings were seen to identify service users’ views and care plans sampled showed that service users had maintained and developed their independence whilst living in the home. Health and safety records were examined. Regular checks of the smoke alarms had been made each week and fire drills had taken place to enable service users to practice how to evacuate the home in the event of an emergency. All service users said they knew what to do in the event the smoke alarms went off. Certificates were in place, which showed that gas and electrical appliances had been tested and serviced for the protection of service users. The home’s fire risk assessment is in need of development to make sure that it explains the fire safety precautions in place, details of fire escape routes and the procedure for response to the smoke alarm sounding so that risks to service users are assessed and minimised. Merryfield DS0000004526.V314649.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 1 2 2 3 X 4 X 5 2 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 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Merryfield DS0000004526.V314649.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 YA1 Regulation 4(1)(c) Requirement The statement of purpose must be updated to accurately reflect the number, qualifications and experience of staff working in the home. The service user guide must be updated to include the range of fees charged and information about the services and facilities provided in the home. The registered manager must ensure that the home has a written procedure for the assessment of potential service users to enable a decision to be made about whether the home can meet the person’s needs. Contracts must be reviewed to ensure that the correct level of fees charged to service users are detailed and that address for contacting the CSCI is accurate. Risk assessments must be completed for service users that go out alone and/or travel independently to minimise risks to their personal safety. Risk assessments must be reviewed on a regular basis. Records of food consumed by DS0000004526.V314649.R01.S.doc Timescale for action 25/11/06 2 YA1 5(1) 25/11/06 3 YA2 14(1-2) 25/11/06 4 YA5 5(1)(b, c) 25/11/06 5 YA9 13(4)(b, c) 30/10/06 6 Merryfield YA17 17(2) Sch 30/10/06 Page 26 Version 5.2 4(13) 7 YA20 13(2) 8 YA20 13(2) 9 YA30 13(3) 10 YA42 23(4) individual service users must be maintained to enable the person reading them to determine that a satisfactory diet is offered and received. Correction fluid must not be used on medication administration records. Recording errors must be investigated and the outcome recorded. Prescribed medicines must be administered to service users at the time stated on the medication administration record. Bars of soap and communal towels must be removed from bathrooms and suitable facilities provided to reduce the risk of cross infection. The fire risk assessment must be reviewed to ensure that fire safety precautions, escape routes and the procedure for response to the smoke alarm sounding are clearly documented. 30/10/06 30/10/06 30/10/06 25/11/06 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 Refer to Standard YA6 Good Practice Recommendations The home should consider archiving out of date information on service users files to make records easier to read for staff. Merryfield DS0000004526.V314649.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Merryfield DS0000004526.V314649.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. 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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