This inspection was carried out on 10th January 2006.
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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Mews The Main Street Bessingby Bridlington East Yorkshire YO16 4UH Lead Inspector
Brian Hallgate Unannounced Inspection 08:45 10 January
th Mews The DS0000063609.V258372.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 Mews The DS0000063609.V258372.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. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Mews The Address Main Street Bessingby Bridlington East Yorkshire YO16 4UH 01262 605340 01262 605340 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) Franklin Homes Limited Miss Marianne Wardle Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: The Mews is registered to provide care and accommodation for up to 5 service users with learning disabilities. It is a period type cottage with the addition of an annex and has its own gardens. Access to amenities is by public transport or taxi to Bridlington town centre. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours, including preparation time. A tour of the home was made and a number of records were inspected. One service user and four staff were seen. Staff were observed interacting with a service user. Key standards not inspected at this inspection were inspected at the previous inspection held on the 10th August 2005. What the service does well: 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. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 6 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 Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 7 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 The statement of purpose and service users guide to the home have been updated to reflect the present position. EVIDENCE: The statement of purpose and service users guides to the home have been updated as recommended at the previous inspection to ensure people considering a placement at the home have the full details on the home before they make a choice. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 8 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 There is a clear and consistent planning system in place to adequately provide staff with the information that they need to satisfactorily meet service users needs. EVIDENCE: In the service users files there are service uses plans of care, risk assessments and a list of dates that the plans and risk assessments have been reviewed. The plans are comprehensive and provide details of service users assessed needs. Clear instructions are provided in the plans to allow all staff to follow the care plans and provide a good consistent standard of care to the service users. The reviews were recorded and up to date. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 9 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): NONE EVIDENCE: Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 10 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 Staff showed a good understanding of the service users’ support needs. EVIDENCE: Staff have access to detailed plans of care for service users that enable them to provide the care that is required. The comprehensive plans are available for each member of staff to read in order to provide a consistency of care to the service users. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 11 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 and 23 There are satisfactory complaints and abuse policies. EVIDENCE: The complaints policy had been updated as required in the previous inspection to give timescales for dealing with any complaints made. There is a complaints book to record complaints. Two complaints had been received from neighbours since the last inspection and these had been dealt with appropriately. The home has a policy on adult abuse. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 12 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 The environment of the home meets the needs of the service users. EVIDENCE: Since the previous inspection new chairs and a new table has been purchased for the kitchen. A tile is the shower area is broken and needs to be replaced. The registered manager stated that the tile identified at the last inspection had been replaced and this was a different tile. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 13 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 and 36 After a period of instability in staffing there is now a good match of staff offering consistency of care within the home. EVIDENCE: A number of vacancies occurred during the last few months for care staff. Interviews have now been held and four new members of staff have been appointed. The night staffing arrangements are now a waking member of staff and two staff sleeping in. Requirements were made at previous inspections that staff must undertake training in breakaway techniques and physical restraint. Despite two timescales for action in the last two inspection reports this training has still not taken place. In view of the number of incidents of challenging behaviour this training is essential for all members of staff. A requirement at the last inspection that staff should receive training in adult abuse awareness has not occurred. A recommendation was also made that staff should receive specialist training in autistic spectrum disorders and, once again, this has not occurred. Two staff have completed NVQ Level 2 awards in care and other staff have commenced this training. Staff also stated that they had been involved in other training courses during the past six months. The home has a policy and procedure on recruitment and the most recent appointment had been made according to the written policy. Staff receive supervision and have an annual appraisal. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 14 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, 40 and 42 The manager has recently been appointed as the registered manager of the home and has a good working knowledge of caring for people with learning disabilities and complex needs. She needs to be given specific management time to undertake the necessary administrative and supervisory aspects of the position. EVIDENCE: The manager of the home has recently been appointed as the registered manager. She has eleven years experience in a variety of care positions and 3 years experience in management. Because of staffing difficulties she has been working virtually full time with service users and has not been able to undertake some administrative and supervisory activities that are required in this home. There are a number of requirements that were made at previous inspections and the manager must be allowed to manage to enable the requirements of inspections to be met. A number of recommendations were also made to ensure that good practice occurs within the home and some of these have not been acted upon. There is a quality assurance document but no quality monitoring exercise has yet been completed to assess the care provided to the service users.
Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 15 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 x x x x Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 1 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mews The Score 3 X X x Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X 2 X DS0000063609.V258372.R01.S.doc Version 5.0 Page 16 YES 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 YA23 Regulation 18 Requirement Timescale for action 31/03/06 2 YA32 13 3 YA39 24 All staff must receive training in breakaway and restraint (previous timescales of 07/03/05 and 31/12/05 NOT MET) and adult abuse awareness (previous timescale of 31/12/05 NOT MET) Staff must receive the necessary 31/03/06 training to enable them to care for individuals with learning disabilities and complex needs Effective quality monitoring 31/03/06 systems must be put in place and implemented RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA32 YA42YA24 Good Practice Recommendations All staff should receive specialist training in autistic spectrum disorder and at least 50 of care staff should have an NVQ Level 2 qualification in care or equivalent The tile in the upstairs bathroom that is damaged should be replaced to ensure that there are no health and safety
DS0000063609.V258372.R01.S.doc Version 5.0 Page 17 Mews The risks. Mews The DS0000063609.V258372.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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