Inspection on 27/09/07 for Merrywick Hall

This inspection was carried out on 27th September 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Merrywick Hall 24/09/09

Merrywick Hall 19/09/06

Merrywick Hall 07/03/06

Merrywick Hall 22/08/05

Merrywick Hall 24/02/05

Merrywick Hall 01/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Merrywick Hall 41 New Road Hedon East Yorkshire HU12 8EW Lead Inspector Diane Wilkinson Key Unannounced Inspection 27th September 2007 10:00 DS0000019695.V352480.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 DS0000019695.V352480.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. DS0000019695.V352480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Merrywick Hall Address 41 New Road Hedon East Yorkshire HU12 8EW 01482 899477 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) Willerfoss Homes Mrs Margaret Rose Scott Care Home 27 Category(ies) of Learning disability (27) registration, with number of places DS0000019695.V352480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2006 Brief Description of the Service: Merrywick Hall is a privately owned care home that provides care and accommodation for up to twenty-seven residents who have a learning disability. The home is located in the town of Hedon on the border of Hull and the East Riding of Yorkshire. It is close to all local amenities including shops, the post office and public houses, and gives access to local transport. The home comprises of a large detached property and a bungalow that has been adapted for residential care use; both are situated within the same wellmaintained grounds and there is a considerable amount of interaction between people living within the two properties. Private accommodation consists of fourteen single bedrooms and four shared rooms in the main house, and the bungalow provides independent living accommodation for up to five people. Communal accommodation consists of two living rooms and a large dining room. Wheelchair users and those with poor mobility living in the main building are accommodated on the ground floor, as there is no passenger or stair lift. Access to and egress from the building are made possible via the provision of ramps. The registered manager confirmed at the time of the site visit to the home that the weekly fees range from £344.50 to £695.00. DS0000019695.V352480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 19th September 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.00 am and ended at 4.45 pm. On the day of the site visit the inspector spoke on a one to one basis with five residents, a senior carer, the registered manager and the registered provider. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered manager submitted information about the service in advance of the site visit by completing and returning an annual quality assurance assessment (AQAA). Survey forms were sent out prior to the inspection; four were returned by residents, two were returned by relatives, two were returned by GP’s, one was returned by a health/social care professional and three were returned by staff. Comments from returned surveys and from discussions with residents, staff and others were mainly positive, for example, ‘they support service users to be as independent as their abilities allow whilst monitoring safety’ and ‘staff and clients are like one big extended family. A large home from home’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. The inspector would like to thank residents, staff and the registered persons for their assistance on the day of the site visit, and to everyone who completed a survey. What the service does well: People are only offered accommodation at the home if an assessment shows that their needs can be met. Care planning at the home is good and people are involved in developing their own care plan. Meal provision at the home is good; people get a choice at every mealtime and mealtimes are a social occasion. People living at the home are supported to maintain their chosen lifestyle, and are encouraged to take part in activities inside and outside of the home, including work and attendance at day centres. This supports people to remain part of the local community. DS0000019695.V352480.R01.S.doc Version 5.2 Page 6 The home provides people with attractive, comfortable, well-furnished, welldecorated and clean accommodation. There is an effective quality assurance system in place at the home that gives people the opportunity to affect the way in which the home is operated. What has improved since the last inspection? What they could do better: There has been one lapse in the safe recruitment of staff; in this instance the risk was minimal, as the person had previously worked at the home. Nonetheless, there is potential for this to result in people being at risk of harm. Some equipment and systems are overdue for servicing; this could place people at risk of harm. There should be an action plan in place that demonstrates how staff will achieve the required qualifications, including the registered manager. Some risk assessments need to be developed that record individual risks and the action to be taken to minimise these. DS0000019695.V352480.R01.S.doc Version 5.2 Page 7 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. DS0000019695.V352480.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000019695.V352480.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are only admitted to the home following a full assessment that evidences that their current care needs can be met. EVIDENCE: The inspector examined admission and care planning records for a new service user. This and other care plans seen by the inspector included a needs assessment, a self-care checklist and a care plan. Some assessment information had not been signed and dated and this makes it difficult for staff and others to identify initial assessment information and any subsequent changes made to the person’s needs assessment. The registered manager informed the inspector that, should a prospective resident make enquiries about admission, they would visit the person at their current address. They would offer a gradual introduction into the care home by arranging day visits, overnight visits etc. as part of the assessment process. This was confirmed by records seen by the inspector. A community care assessment and care plan is obtained from the local authority that has commissioned the placement and this is used along with the DS0000019695.V352480.R01.S.doc Version 5.2 Page 10 home’s own assessment to develop an individual care plan for the person concerned. There is evidence in care plans that family members and health/social care professionals are involved in the assessment and care planning processes; associated correspondence was seen by the inspector. DS0000019695.V352480.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 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning provides an up to date record of a person’s care needs, and staff encourage and support decision-making and responsible risk taking. EVIDENCE: Care records for existing service users were seen to include a full assessment of needs that had been undertaken by the home, as well as a community care assessment/care plan produced by the commissioning local authority. These documents were used to inform the development of an individual care plan. The inspector observed that people have signed to agree to the content of their individual plan of care. Records seen by the inspector evidenced that appropriate risk assessments and hazard identification forms had been completed, including those for going out unsupervised, use of the call system and communication difficulties. As a DS0000019695.V352480.R01.S.doc Version 5.2 Page 12 result of moving and handling assessments, service users are provided with any equipment they need, such as wheelchairs and bed rails. People’s specific medical needs have been well recorded to assist staff in working with people in an effective way. The inspector observed in care plans that referrals are made to appropriate health and social care professionals on behalf of service users, such as community psychiatric nurses, learning disability nurses, physiotherapists and care managers. Care plans are monitored in-house monthly, six-monthly and annually in addition to formal reviews that are organised by the local authority. Records seen by the inspector evidence that staff complete documentation prior to the formal review as requested, and that the resident and their key worker attend the review. The inspector asked the registered manager if care plans could be made available in a language and format that could assist service users to have a better understanding of the documentation. The registered manager informed the inspector that pictures have now been identified that can be used for this purpose, and that they intend to incorporate these into care plans shortly. On the day of the site visit some people were attending day centres and others were out at work. Staff chatted to them about their day on their return to the home. Key workers record in ‘quality time log sheets’ – these are detailed accounts of the time key workers spend with people encouraging and supporting them with day-to-day tasks and activities. There was no photograph in one resident’s care plan but other care plans seen by the inspector included a photograph. A photograph is needed to assist new staff with identifying service users, and in the event of a service user going missing from the home. DS0000019695.V352480.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 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users’ nutritional needs are met and they are supported to make choices about their day-to-day lives. Service users are supported to maintain links with family and friends and opportunities for taking part in age appropriate activities within the local community are promoted. EVIDENCE: The AQAA submitted by the registered manager recorded that some service users go out to work, some attend a local day centre, some attend adult education classes and some do voluntary work. In-house activities are available for those people who remain at the home during the day, if they choose to take part. On the day of the site visit people were talking to each other and to the inspector about the karaoke that would be taking place that night. The inspector observed that there is constant communication between DS0000019695.V352480.R01.S.doc Version 5.2 Page 14 residents and staff, and that staff understand the individual needs of each resident. People’s bedrooms included items that evidenced they were encouraged to have individual hobbies and interests, such as doll collections, CD’s, DVD’s and posters of artists seen in clubs in the local area. A health care professional recorded in a survey, ‘All staff appear to have worked in the service for a number of years, and so know the individuals very well’. Staff support service users to maintain family links and friendships – care plans evidence that some service users spend time out of the home with their family. Personal relationships are supported if they are appropriate and if both parties are happy with the relationship. People were happy to tell the inspector about their time spent at the day centre and things they had achieved at day centres, work or adult education classes. The inspector observed on the day of the site visit that service users were supported to make decisions about their day to day lives, such as where to spend their day, when to eat meals and who to socialise with. The registered manager recorded in the AQAA that residents are encouraged to have specific domestic tasks throughout the home. People were seen to take their aprons to the laundry room after lunch and to be involved in tidying or cleaning their rooms. The inspector observed information in one care plan about the involvement of an independent advocate; this evidences that the home are able to access this service on behalf of service users. A social care professional recorded in a survey, ‘the service supports service users to be as independent as their abilities allow whilst monitoring safety’. At the time of this site visit, seven residents were on holiday in Spain – they were accompanied by two staff from the home, and other carers were included in the trip. People had paid for this holiday themselves, with no contribution from the home. Other residents told the inspector that they are going on holiday in this country. The registered manager informed the inspector that some residents do not like going away overnight, and that they have day trips out instead of a holiday. This is recorded under ‘decision making’ in care plans. One resident had asked for a special outing to be organised by staff at the home; this involves a certain amount of risk and the need for the resident to be accompanied by a member of staff. The registered manager is in the process of consulting health and social care professionals about this outing, and told the inspector that she would be undertaking a risk assessment to evidence that any identified risks had been minimised. The inspector observed that the kitchen was clean and hygienic on the day of the site visit. Because many residents are out during the day, the cooks start work late morning so that they are able to prepare a snack lunch and a cooked evening meal. The inspector spoke to one of the cooks and examined menus on the day of the site visit. There is no standard menu in place; the cook told DS0000019695.V352480.R01.S.doc Version 5.2 Page 15 the inspector that he prepares menus on a daily basis that are based on the likes and suggestions of residents, and on how popular dishes have been in the past. The menus and the meals requested by each resident are recorded; these records evidence that there are three or four choices available for the evening meal. The cook told the inspector that he talks to the residents each evening about the choices for the next day. The inspector suggested that a menu for each day could be displayed to encourage independence and communication between residents, and the cook agreed to try this. The inspector observed the serving of lunch and noted that mealtimes were informal and social events for residents, with appropriate assistance being offered by staff when needed. A service user’s likes and dislikes regarding food and any food allergies are recorded in care plans. One relative said in a survey, ‘Excellent food’. DS0000019695.V352480.R01.S.doc Version 5.2 Page 16 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 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and their health care needs are met. Medication procedures and staff training on the administration of medication are robust providing a safe system that protects service users. EVIDENCE: The inspector observed that staff respect the privacy of service users; service users were spoken to sensitively about personal care issues and staff knocked on bedroom, toilet and bathroom doors before entering. Care plans record preferred times for getting up, going to bed and choices regarding meals and other activities and people living at the home told the inspector that this was the case. There is evidence in care plans that specialist health and social care professionals are involved appropriately in the care of service users, such as physiotherapists, psychiatrists and community learning disability nurses. The AQAA submitted by the registered persons records that there is one male care worker employed at the home and this gives residents the opportunity to DS0000019695.V352480.R01.S.doc Version 5.2 Page 17 be assisted with personal care by a male should this be their wish. The inspector overheard conversations about baths, hairstyles and clothes between residents and staff, and observed that people are supported to choose their own clothes, hairstyle and makeup and that their appearance reflects their personality. Care plans include thorough details of a service user’s health care needs, and evidence that a service user’s health is monitored and potential problems are identified and dealt with at an early stage. There is evidence in records that a variety of health and social care professionals are involved in a person’s reassessment when problems have been identified. There was no evidence in care plans that service users had an annual health check, although there is evidence that GP’s are called out as necessary, and that referrals are made to specialists when needed. Service users are weighed as part of nutritional screening, and people that are known to have seizures have monitoring charts in place. The inspector observed the administration of medication on the day of the site visit. The member of staff that administered the medication took the medication to the person concerned and ensured that the medication had been taken before signing medication administration records. Medication is stored in a locked medication trolley that is kept in a small room close to the manager’s office. Colour coded blister packs are provided by the Pharmacist to identify tablets that are prescribed for morning, lunchtime, teatime and evenings. Medication administration records were examined and these were found to be accurate. There is a record of the staff that are trained to administer medication and a sample of their signature in the medication administration records. None of the current service users self medicate and this is reflected in care plans. The registered manager told the inspector that none of the current residents are prescribed controlled drugs. There are suitable storage facilities and a controlled drugs book is available should these be required in the future. The registered manager told the inspector that medication such as insulin is stored in a locked cash box in the fridge; there is a separate medication record for staff to sign this medication in and out and to record a ‘running total’. The inspector recommends that a separate lockable medications fridge be purchased to increase security and to ensure that medication is stored at the correct temperature. Temperature records would have to be maintained for a medications fridge, if purchased. DS0000019695.V352480.R01.S.doc Version 5.2 Page 18 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 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People know how to use the complaints procedure and records evidence that any complaints received are dealt with in an open and transparent manner. Staff understand the policies and procedures in place on safeguarding adults and this offers service users protection from the potential to be abused. EVIDENCE: The inspector noted that the complaints procedure is displayed in the home. The inspector examined the complaints log and this evidenced that all recorded complaints had been dealt with in a satisfactory manner, and within given timescales. All of the residents that returned a survey said that they knew who to speak to if they were unhappy; in most instances, they said that they would speak to a member of staff. Staff that completed a survey recorded that they knew what action to take if a resident or relative had any concerns about the home. One relative that returned a survey said that they did know how to make a complaint whereas another said that they didn’t. One relative said in the survey, ‘never had to complain in 10 years’. There are satisfactory policies and procedures in place on safeguarding adults, and training records at the home evidence that most staff have undertaken this training. The AQAA completed by the registered persons records that there has been one safeguarding issue at the home; the CSCI were notified of this at the time and there is evidence that the situation was dealt with in a satisfactory manner. DS0000019695.V352480.R01.S.doc Version 5.2 Page 19 People told the inspector on the day of the site visit that they would tell staff if they had any concerns, complaints or worries, and were sure that staff would help them. DS0000019695.V352480.R01.S.doc Version 5.2 Page 20 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 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides people with clean, safe, homely and comfortable accommodation. EVIDENCE: There is a maintenance programme in place and a handyman is employed to carry out day-to-day maintenance of the home; they were present on the day of the site visit. The premises were found to be safe, comfortable and well maintained on the day of the site visit; they provide sufficient light, heat and ventilation, and radiators are guarded to control the risk of burning for service users. Furnishings, fittings, adaptations and equipment are of good quality, although there was some surplus mobility equipment in one bathroom that needed to be removed; the registered manager agreed to move these items. DS0000019695.V352480.R01.S.doc Version 5.2 Page 21 The premises are in keeping with the local community and the home offers access to local amenities, local transport and relevant support services. The premises meet the requirements of the local fire service and environmental health department. One person had ‘wedged’ their bedroom door open and the registered manager told the inspector that they would explore the provision of a door closer that is attached to the fire alarm system. Residents currently smoke outside and relatives and health/social care professionals commented in surveys that this should be rectified by the time the cold weather arrives. This was discussed with the registered provider on the day of the site visit and they agreed that provision would be made for residents who smoke, either in a dedicated room within the home or in a ‘lean to’ or shed that can be easily accessed by residents. The premises were seen to be clean on the day of the site visit and there were no unpleasant odours. Laundry facilities are satisfactory and soiled laundry is not carried through areas where food is stored, prepared, cooked or eaten and facilities do not intrude on service users. The laundry room has two washbasins; one is used as a sluicing facility and the other is used by staff to wash their hands; the inspector recommends that a sign be placed over the washbasins to record their use. Hand washing or disinfection facilities need to be provided for staff to promote good infection control. The training programme records that most staff have undertaken training on infection control and the inspector observed good hygiene practice being used by staff on the day of the site visit. There is no evidence that the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999; the registered manager agreed to contact a plumber to take advice about this. DS0000019695.V352480.R01.S.doc Version 5.2 Page 22 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 and 35 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are well trained but most have not yet achieved recommended qualifications. Recruitment policies and practices do not fully protect service users from the potential to be abused. EVIDENCE: Two care staff are working towards National Vocational Qualifications (NVQ) at Level 2 in Care and staff recorded in surveys that they are due to commence the Learning Disability Awards Framework (LDAF) training in October 2007. The home has not achieved the target to have 50 of care staff with NVQ Level 2 in Care and must have an action plan in place to demonstrate how this will be achieved. The inspector examined the recruitment records for three staff. These evidenced that an application form is completed by prospective staff and that two written references are usually obtained prior to staff commencing work at the home. A Criminal Records Bureau (CRB) check or Protection of Vulnerable Adults (POVA) first check are obtained prior to people commencing work in DS0000019695.V352480.R01.S.doc Version 5.2 Page 23 most instances. In one instance someone started work just before one reference and the POVA first check were received. The registered manager told the inspector that this was an oversight; this person had previously worked at the home as a senior carer so was well known to the manager. The registered manager was reminded that a POVA first check should only be used in exceptional circumstances. Under normal circumstances, a CRB check should be obtained prior to staff commencing work at the home. There is evidence that staff receive a copy of the Code of Conduct and Practice set by the General Social Care Council. All staff that returned a survey recorded that ‘there is always room for improvement’ and that they are learning new things all of the time; this is a positive attitude towards learning and development. The training programme evidences that staff undertake a variety of training programmes, and this is supported by information seen in individual staff records. Most staff have undertaken training on safeguarding adults, health and safety, fire safety, moving and handling, first aid, infection control and food hygiene. The training programme records the date that training was undertaken by staff; this assists the registered manager to recognise when refresher training is needed. Staff records evidence that Induction training does take place for new staff but that it is not usually achieved within the recommended 6-week period. The registered manager told the inspector that new Induction workbooks have been obtained for staff but that these are not yet in use. DS0000019695.V352480.R01.S.doc Version 5.2 Page 24 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 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the quality assurance system gives people the opportunity to affect the way in which the home is operated. The health, welfare and safety of service users are protected, with the exception of risk assessments regarding specific activities and some ‘out of date’ service certificates. EVIDENCE: The registered manager is a qualified nurse; she has the skills and experience to manage the service but is now planning to retire. Because of this, she has decided not to undertake NVQ Level 4 in Care and Management. On the day of the site visit the inspector was informed that the post of manager has been advertised. It is planned that the current registered manager will continue to work at the home for a short while, working alongside the new manager as DS0000019695.V352480.R01.S.doc Version 5.2 Page 25 part of their induction to the role; this is good practice. One GP that completed a survey commented, ‘this is overall a well organised home’. The registered manager of the home is continuing to support another care home in the group that does not currently have a manager. The registered manager feels that, because she has a good staff team at Merrywick Hall, the residents are not affected by her absences. There is a quality assurance calendar in place; this includes a complaints log, a record of resident and staff surveys and a record of internal audits. A survey form was sent to residents and staff in June 2007 and this information is in the process of being collated. The registered manager told the inspector that any issues raised have been dealt with individually, and that the collated information is included in an ‘end of year’ report. The inspector recommends that this information is displayed in the home or discussed at resident and staff meetings. This would inform those that have taken part in surveys of the outcome and any actions that are to be taken as a result of their comments. Internal audits take place on such topics as care plans, daily reports, risk assessments and reviews. Any action taken as a result of collating information from these audits is recorded. Staff meetings take place about every three months and the inspector examined minutes of these meetings. These evidence that such topics as residents’ holidays and any particular concerns about individual residents are discussed. Residents meetings are also held. Health and safety documentation was examined by the inspector on the day of the site visit. This evidenced that all equipment has been serviced on a regular basis and that an annual test of the fire alarm system has been carried out, including emergency lighting and fire extinguishers. The electrical installation was tested in July 2006, the call system was serviced in October 2006 and a portable appliance test was carried out in June 2007. There is a gas safety certificate in place until 13.9.06 – this was slightly overdue for servicing. Records evidenced that the bath hoist was serviced in June 2006. Again, this work was overdue. The registered manager agreed to ensure that both of these services were arranged as soon as possible and to inform the CSCI that this work has taken place – this has not been received at the time of writing this report. There has been an overall review of the risk assessments in respect of the building; these constitute a written statement of the policy, organisation and arrangements for maintaining safe working practices, including associated risk assessments. Water temperatures are tested every time someone is assisted with a bath, and routinely in washbasins in bathrooms and bedrooms. One person has a bath unassisted by staff; this is to be encouraged but there should be a risk DS0000019695.V352480.R01.S.doc Version 5.2 Page 26 assessment in place to record that any risks have been identified and addressed. The AQAA indicates that there are written assessments in place for the Control of Substances Hazardous to Health (COSHH). At the last inspection it was noted that there were no risk assessments in place for the use of bed rails and bumpers. Following the inspection, the registered manager arranged for those residents that use these to be reassessed; this resulted in new equipment being provided. These are checked daily by staff but the inspector recommends that someone be nominated to check these thoroughly on a regular basis (using information recently issued by the Medicines and Healthcare products Regulatory Agency), and for these checks to be recorded. DS0000019695.V352480.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X DS0000019695.V352480.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 Requirement Two written references and a satisfactory CRB check (or POVA first check in exceptional circumstances) should be in place prior to staff commencing work at the home. Timescale for action 27/09/07 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. Refer to Standard YA2 Good Practice Recommendations Assessment information should be dated to evidence that the assessment process commenced prior to the person’s admission, and to assist staff and others with identifying the initial assessment information and any subsequent changes to a person’s assessed needs. The home should include in the basic contract price the option of a seven-day annual holiday for residents. The inspector recommends that a menu be displayed to promote independence and encourage discussion between residents. The registered person should consider purchasing a separate lockable fridge for the storage of medicines to ensure that they are stored at the required temperature. DS0000019695.V352480.R01.S.doc Version 5.2 Page 29 2. 3. 4. YA14 YA17 YA20 5. 6. YA30 YA30 7. YA32 8. 9. 10. YA37 YA39 YA42 11. 12. YA42 YA42 The registered person should provide evidence that the home meets the Water Supply (Water Fittings) Regulations 1999. Washbasins in the laundry room should be clearly labelled; one should be used for sluicing and the other should be used for staff to wash their hands. There should be facilities in place for staff to disinfect their hands. The registered person should ensure that there is an action plan in place to demonstrate how they will meet the requirement for 50 of care staff to have achieved NVQ Level 2 in Care. The registered manager should be working towards a management qualification to supplement her nursing qualification. The outcome of quality surveys should be published to inform all those that have taken part in surveys of the action taken in response to comments made. The registered person should ensure that all maintenance is kept up to date; servicing of gas appliances/systems and the bath hoist were overdue on the day of the site visit. (This work was subsequently undertaken by contractors as soon as it could be arranged by the registered person. Evidence of this was seen by the inspector). Regular safety checks of bed rails and bumpers should take place and these should be recorded. There should be risk assessments in place for people who have ‘unassisted’ baths and for any particular activities that people wish to take part in where there is an element of risk. DS0000019695.V352480.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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