Inspection on 29/08/07 for Mimosa

This inspection was carried out on 29th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mimosa 27/06/06

Mimosa 19/12/05

Mimosa 20/06/05

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 Mimosa 4 Shirley Road Hanley Stoke on Trent Staffordshire ST1 4DT Lead Inspector Ms Wendy Jones Draft - Unannounced Inspection 29th August 2007 11:30 Mimosa DS0000064017.V339655.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 Mimosa DS0000064017.V339655.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. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mimosa Address 4 Shirley Road Hanley Stoke on Trent Staffordshire ST1 4DT 01782 280838 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd Vacant post Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Mimosa is a residential care home providing 24 hour care for five people with a learning disability and mental health concerns. The accommodation provides for one double and three single bedrooms. The home has a lounge and separate dining room and there is a small garden area at the rear of the property. The home has bathing and shower facilities - the bathroom being upstairs and the shower downstairs. There is no on site parking. The home shares the use of two people carriers with five other care homes in the vicinity owned by the same company. The home is located close to Hanley park and in the area there are some local shops. A short distance away there are other amenities such as medical services, a hairdresser and leisure facilities. Residents can attend a local college for a number of sessions a week and join with service users from the neighbouring care home to go out on trips and on holiday. The home offers some activities at the home. Service users are involved in day to day activities associated with running the home including ensuring their bedrooms are tidy and clean and with washing up, laying the table and shopping. The home has a staffing level of one care staff on at any time. The Care Manager has the responsibility for the care home next door. The current fees are between £333 - £503 per week. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit carried out on 29 August 2007 by one inspector over a period of 5.5 hours. The visit consisted of discussion with the deputy manager and another member of staff; from discussion with all 5 residents; from observation of the environment and of interactions between residents and the care team. A range of records were also looked at, including care plans, medication charts, staff rota’s, records of staff and resident meetings, fire safety information and menu’s. No complaints have been received since the last key inspection in June 2006, and no Safeguarding referrals have been made. An additional inspection visit to the home was carried out in November 2006. 4 requirements and 6 recommendations have been made as a result of this visit. The service has responded positively to the report and has confirmed the action they will take to ensure that they meet the requirements and recommendations indicated. What the service does well: Residents said that they are happy living at Mimosa, one said “this is my home, I like it here, we are a family.” The service promotes resident’s independence as much as possible and encourages them to choose how they spend their day. It provides a 7-seater vehicle for any transport needs, and most resident have bus passes for public transport. Regular residents meetings are held with the people using the service both in groups and individual sessions and a resident has been supported to become a member of a resident’s forum. Which means meeting with residents from other homes managed by the organisation to discuss things that they want to change or that are important to them. The pre inspection information for the home includes a statement that the service strives: “To ensure that service users views are at the foremost of our service we ensure that the following are done; monthly residents meetings, 1-2-1 sessions with designated keyworkers, reviews and also the completion of regulation 26 visits by the area manager monthly.” Care plans and risk assessments are developed for each resident and there is evidence that these are discussed regularly with each individual are regularly reviewed. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 6 Health needs are closely monitored and the people using the service are supported to access the appropriate health professionals. Personal care needs are met and residents privacy and dignity respected. The systems in place for the safe management and administration of medication are robust. There have been no complaints made about the service to the Commission for Social Care Inspection and residents said that they felt able to discuss any concerns they may have with staff. A complaints procedure has been created in a user-friendly format. Each person has their own bedroom and they are encouraged to personalise them. Most of the people using the service have keys to the house and their bedroom. There is sufficient communal space provided and the home is a pleasant place to be. Staff receive regular training, both mandatory and to meet the specific needs of the resident group, individual supervision sessions and team meetings are held monthly. Staff recruitment procedures ensure that appropriate checks are undertaken to ensure the safety and well being of residents. What has improved since the last inspection? As a result feedback from residents a re-organisation of in and out house activities has been conducted with a much more service user centred approach being adopted. This has included activities such as in-house meal preparation and weekly house shopping. A more user friendly complaints procedure has been developed, and changes to service user guide have been made. The person centered plans. Are continuing to be developed. Implemented individual talk times documentation (1 to 1 discussions with key workers) To facilitate and encourage individual personal wishes/choices and weekly planning for the persons preferred activities. All staff have completed training on administration of medication. New kitchen worktops have been fitted and the kitchen walls have been repainted. Lighting in the communal lounge has been altered to improve the atmosphere in the home. The Acting manager has achieved NVQ4/RMA from City and Guilds Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Mimosa DS0000064017.V339655.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 Mimosa DS0000064017.V339655.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): 1,2 and 5 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will receive information about the service, it’s facilities and the terms and conditions of residency, this information ensures that they can make an informed decision about moving in to the home. But they cannot be sure that this information is produced in a format that is easy for them to understand. EVIDENCE: The deputy manager reported that the Statement of Purpose and Resident Guide have been up dated and further work was being carried out to produce both documents in a more user- friendly format. Each resident has copy of the resident’s guide in his or her bedrooms. The information in the terms and conditions of the document has been up dated to show the current fees and the cost resident’s incur for transport etc. It was recommended that the Resident Guide should also include a copy of the inspection report and any comments received from residents on the quality of the service. Residents knew what the Resident Guide was and had opportunities to talk about its contents during their one to one key worker time. Residents said they were happy with the service and said it was their home, one resident said, “ we all get on and look after each other.” They have all lived at the service for some time. There are no pre admission assessments on residents’ files, but more recent assessment of care needs have been carried Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 10 out and these are reviewed with care plans on a regular basis. In the pre inspection information provided by the acting manager, she says “there have been no new admissions to the home since 2005, but a new admission procedure and documentation has been produced, should we have a vacancy and a referral to the service. We will ensure that all pre-admission assessments are carried out, that the prospective resident has the opportunity to visit the service and will undertake to ensure compatibility with the current resident group.” Mimosa DS0000064017.V339655.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, 8 and 9. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they are involved in the implementation of their care plans and usually involved with the regular reviews of their care. They cannot always be sure that their right to live an independent lifestyle is not compromised by the needs of other residents. EVIDENCE: The care planning system is being developed to incorporate a more person centred approach this means that the resident is involved in all areas of the care plans and decision making. The deputy manager stated that the new format for plans had been introduced and the service was in the process of transferring relevant information to the new format. There is good evidence of care planning although some are not dated which makes it difficult to establish how relevant they are. There is evidence that review and evaluations of plans take place but not always the evidence that residents are involved in these. Residents confirmed that “ my key worker Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 12 does talk to me about my care,” “I do talk about the things I want to do.” “ I keep my care plans in the office, the staff look after them.” The service has a well-established plan for individual “talk time” where the individual resident meets on a one to one basis with their key worker to discuss their plans and to make changes if necessary. A key worker is a named care worker for the resident to go to if they have any matters they need to discuss, the role also includes supporting resident to maintain contact with family and friends, support them with health appointments and social outings, support them to make changes to care plans and attend any formal reviews of their care with them among other things. Included in the care records are individual risk assessments these are detailed and look to have been developed with residents and if necessary other parties to ensure that any identified risk is minimised. In one example the risk was identified and reported verbally during this visit had not been included in the recorded risk assessment for the individual resident. And it was felt that steps to reduce the risk while promoting resident independence had not be considered. This risk related to access to the kitchen, and a resident who smoked, and will light cigarettes on the gas stove, presenting a risk to themselves and to other if the gas is not turned off properly. To address this decision has been made to lock the kitchen at all times, with access only available for residents when staff are in attendance. A resident said, “ if I want a drink I ask the staff, but I can’t just go in the kitchen to make one because it has to be locked.” This issue was discussed at the random inspection visit in November 2006; the service needs to consider how it can make changes to ensure that resident’s rights are not compromised while ensuring their safety is assured. It was not clear that this matter had been thought through or discussed as part of a responsible risk taking strategy. Mimosa DS0000064017.V339655.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, 15, 16 and 17. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Residents can be sure that they will be supported to maintain relationships with families and friends to access social, leisure and recreational opportunities, to have the opportunity for a holiday or day’s out if they want them and to have involvement in planning menus to ensure that they have a choice of meal at each mealtime. But they must also be sure that if staff need to accompany other residents out of the home that there are always other staff provided to support them in their home. EVIDENCE: Records show that residents have care plans in place relating to occupation and community presence, and there is evidence that these plans are being followed. Most residents have some type of formal activity such as college classes; others have chosen not to participate in this type of opportunity preferring a more sedentary lifestyle with recreational and social activities. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 14 All residents have a bus pass, some are able to use these independently, and others need to have some support form the care team. The service also has it’s own transport. All residents are to go on a planned holiday to a holiday cottage in September, residents said, 2 looking forward to going on holiday,” we’ll have a good time,” for some this is the second holiday they have had this year. Others will have/ have had an opportunity for day trips and short breaks on an individual basis. The Resident Guide contains basic contract details including the costs of the transport residents are expected to meet. This is calculated at £18 per month. The contracts also state that the residents will meet the whole costs of an annual holiday with the organisation meeting the staff salary costs only. Due to some staffing restrictions it was reported that there have been occasions when residents have had to go to the home next door, while other residents and the member of staff go out to the shops or attend an appointment. This arrangement is not satisfactory and the service needs to review the staffing position to ensure that sufficient hours are provided to ensure that this type of thing does not occur. It is not right that resident are moved out of their own home at these times due to a lack of staff numbers. The assistant manager stated that some additional management hours are provided and this should not happen. Staff and residents meetings are held regularly and the company has introduced a resident forum recently. This is where a resident representative of each of the local homes meets with others to discuss common issues and identify means of resolving them. It intended that minutes of these meetings would be circulated to all the homes and each forum member. The representative for the home stated, “ I go and talk about the things we want to do or change here, or things that we don’t like, they listen and try to put things right.” Those residents who have relatives and friends are supported by the service and their key workers to keep in touch and visits are arranged when necessary. Residents have menu-planning meetings once per week where they agree the meal choices for the following week and are able to plan the food shopping accordingly. Menu plans are available and it was clear that residents in this home prefer a more traditional fare. Choices to the main meal were not recorded, but there was evidence during this visit that residents could have an alternative to the main meal offered. They said, “ The food is good,” “ I can ask for what I want really.” “Staff know what I like.” It is understood that all resident are registered on the electoral register to vote. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will be supported with the personal care and can be confident that their health and medication needs can be met by a staff team that is sensitive to their needs. EVIDENCE: Residents said “staff help me if I need it.” “I have my own key to my room so I lock it if I need to.” Health care needs of resident are well met with regular appointments to chiropody, dental and ophthalmic services arranged. Residents are also supported by staff to attend hospital appointments. Information provided in pre inspection records states that residents are also supported to access preventative heath checks such as breast screening etc. The service has policies and procedures for the safe management, handling storage and administration of medication. The medication file contains individual Medication Administration Records (MAR) that have the information regarding the medication for each resident and instructions for its Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 16 administration recorded on them. From the sample seen the staff are signing the records appropriately. Medication is dispensed from the pharmacy in blister packs, for those residents who don’t self medicate and in individual bottles for those that do. Risk assessments have been put in place for the resident who currently self medicates and they have a lockable facility in their bedrooms to safely store the medication. The general medication storage facility is limited in terms of size. The assistant manager stated that they were considering changing it to provide more suitable storage space. But it is locked and secured to the wall. No controlled drugs are currently stored in the home. All staff have completed training in the administration and safe handling of medication and re-assessments of staff are to be completed on a 6 monthly basis. Medication training is reported to have included both ASET Level 2 certificate in managing the safe handling of medication, and Care Techs comprehensive Administration of Medication course following Skills Council specifications. In the pre inspection information the acting manager has stated that residents generally have chosen to not discuss any plans of wishes that may have for funeral arrangements, bequests or estate management. It is understood that at least one resident has discussed their preferred arrangements and details with a legal representative. And the service has indicated that it will ensure that they “continue to work with residents around this sensitive issue in a way and at a pace that they feel comfortable with.” Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that any concerns they have will be dealt with properly and promptly, and be confident that where abuse is suspected staff have the skills and training to know how to protect residents and how to report the concerns. EVIDENCE: A Complaints procedure is on display in the home in a form that is user friendly, it is also included in the resident guide. Resident said they were happy at the home, and said, “ If I have any problems I go to the staff or the manager,” In pre inspection information the acting manager has stated that no complaints had been received at the home, and no complaints have been referred to the Commission for Social Care Inspection in respect of this service. Staff have received training in recognising and reporting abuse and the vulnerable adults procedures agreed locally, there is also a procedure in place in the home and a whistle blowing procedure as well. No safeguarding referrals have been made since the last inspection. The service keeps the CSCI informed of any accidents or incidents in the home. A sample of residents’ finances showed that receipts are kept for every transaction, running totals are Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 18 maintained along with records of purchases and regular audits of the records take place. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 19 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, 26, 27, 28 and 30 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home in which they live is clean and comfortably furnished, and can be sure that they will be consulted about any changes. This ensures that they are able to have some control over their environment and are able to drive forward any changes they identify. EVIDENCE: The homes appearance is in keeping with the local housing stock. No obvious signage is attached to the home to identify it as a care home. Some improvement to the interior of the home has been made since the last key inspection. A new television has been provided in the main lounge and the resident have “Free View” as well. The dining room was being decorated at the time of this visit. Others areas such as, redecoration in the lounge has been discussed. Residents confirmed that they have chosen a colour scheme for this room. One resident also stated that the sofa has stained arms and Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 20 despite efforts to clean them it remains stained, this should be considered for deep cleaning or replacement. The ground floor shower room is in need of up grading; it is functional but not a very attractive facility. The kitchen is basic and it is understood that the work surfaces have been replace, but further work would improve this facility. The laundry is a shared facility with the home next door and in an out building to the rear of the property. Residents have their own bedroom none of which are en-suite. There are four bedrooms on the first floor and one on the ground. Residents have the choice of having a key unless a risk assessment indicates that this is not an option. Residents said that they had a lockable facility in their bedrooms. Communal space includes the main lounge which has sufficient seating space for all residents, and the dining room to the rear of the property which has seating space for six, this also has a CD player and provides resident with an alternative area to sit, if they want to be by themselves, it also leads on to the main garden area. Residents who smoke can do so in the garden area. The first floor also contains the homes office and the main bathroom, the assistant manager stated that requests have been made for the bathroom to be upgraded this includes replacement of flooring and redecoration. The first floor landing has been noted to have floor boards evident beneath the carpet, some of which were a little uneven, its recommended that the service considers replacing the carpet and ensuring that it has sufficient underlay to reduce this potential trip hazard. A new maintenance system is in operation and is reported to be efficient, requests are prioritised and action taken to resolve them in a timely manner. The staff undertake a number of daily and weekly visual health and safety checks of the building including checking the hot and cold-water temperatures. The records of these showed that the hot water is controlled from the main boiler, this means that the water temperature for the baths and wash hand basins is at the recommended level the hot water in the kitchen is not at a sufficient temperature to wash the dishes. This matter will be referred to the EHO department of Stoke-on-Trent city council for their advice. In addition the boiler which is located in the staff sleep in room/ office is currently set so that if hot water is need the heating also comes on, the room temperatures were really uncomfortably hot during this visit, and it is suggested that staff are instructed how to operate the heating and water separately. The current location in the sleep in room is not ideal and information in the records available indicates that an alternative location is being considered. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 21 The service has stated in feedback to the report that, “the hot water temperature is being monitored by staff in-house and has been further checked by the maintenance department, who were required to make a slight adjustment to ensure that correct temperatures were reached. All staff who work in Mimosa are aware of the workings of the heating system and are able adjust heating levels from the boiler where needed.” Mimosa DS0000064017.V339655.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, 33, 34, 35 and 36 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The people using the service benefit from being supported by staff that are well recruited and supervised and trained to meet their needs. But staffing levels need to be kept under review to ensure there are sufficient staff provided to meet the individual needs of residents. EVIDENCE: Residents said, “ the staff are great,” “ we can talk to them and they help us.” During this visit the member of staff on duty was ill, but had not been able to secure staff support to cover the shift. The on call manager was spoken to who agreed that replacement staff cover was needed and made every effort to ensure this was arranged. Staffing levels are usually one person throughout the waking day and one sleeps in at night. These arrangements are supplemented by additional hours provided by the acting or deputy manager at times during the week, but are not necessarily daily. This can create difficulties if residents want to go out of Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 23 the home or shopping is planned the service should keep staffing levels under review to ensure that the individual needs of all residents can be met. The turnover of staff since the last inspection has been low, no new staff have been employed to work at the home. A check on recruitment files was not undertaken during this visit as a result of this information and the fact that the CSCI have confirmed that checks carried out on recruitment records held at the company office are satisfactory. The current acting manager stated that all staff have received mandatory training in the pre inspection information4 staff are employed at the home 2 have an National Vocational Qualification (NVQ) at level 2. Standards of staff supervision are good, regular monthly staff meetings are held. Mimosa DS0000064017.V339655.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, 42 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they live an environment where health and safety and fire safety checks are undertaken regularly, but cannot be certain that all staff have attended a recent fire drill. Quality auditing systems are in place but the organisation should develop these further to ensure that the view of all parties who have an interest and stake in the service are taken into account, to inform the future development and improvement of the service. The service must recruit a suitably qualified and experienced manager. EVIDENCE: Notification from fire safety officer confirms that the service is compliant with new fire safety regulations. Staff have received fire safety training and some Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 25 have been involved in fire drills, the assistant manager was asked to ensure that all staff are involved in two fire drills per year. Servicing records showed that all equipment had been serviced recently this included the gas boiler and cooker, electrical pat testing and the fire alarm system. Monthly visit to the home are carried out by the area manager where an assessment of the conduct of the service is undertaken, reports of these visit should be provided in the home it was established from records that the visits have taken place but the reports of the visits have not always been received in a timely manner this should be resolved the last received report seen is dated 03/07. Quality audits are undertaken by the acting manager on a monthly basis and periodically by the company. The last audit is dated December 2006 with the service achieving an 82 score, there was evidence in the records that any action points had been addressed by the acting manager. The need to extend the quality system further was also discussed during this visit, by seeking the views of resident their relatives and representatives and other interested parties. The outcome of these surveys should be circulated to residents, and included in the service user guide the service should then produce a development plan based upon the finding s for the following year. The acting manager confirmed that improvements to the quality assurance systems are to be introduced. We have been informed that Caretech has a dedicated quality and performance team and “a full audit is due to be undertaken within the next two months. Caretech are also developing a self-assessment tool for services to critically evaluate the support that they provide. The quality and performance team are in the process of devising an accessible satisfaction survey for residents and surveys for relatives and professionals. It is envisaged that responses from these will be collated by a panel which will have service user representation and this will enable Caretech to develop its services using person centred approaches.” The current care manager’s position is vacant; this has been the case since November 2006. An acting manager has been appointed and has continued in that role. She has achieved NVQ level 4 in care and management. The vacancy has been advertised and a recruitment process undertaken, a successful candidate was identified but the position has yet to be filled and a new recruitment drive is necessary. This matter will be managed in a separate letter to the organisation. Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 3 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 x LIFESTYLES Standard No Score 11 x 12 3 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 2 x 2 x x 2 x Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 27 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 YA42 Regulation 23 Requirement Staff must attend fire drills to ensure they know what to do in the event of a fire. The registered person must recruit a suitable manager and submit an application to register that person to the Commission for Social Care Inspection. 3. YA27 23(2)(d) 29/11/07 The ground floor shower room must be refurbished to provide a more suitable and safe environment for the people using the service. Review the risk assessments 29/11/07 relating to the resident who has been identified at risk because they smoke. And ensure that any action does not compromise the rights of other residents. Timescale for action 29/11/07 2. YA37 9 29/11/07 4. YA9 13 Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 28 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 YA21 YA6 Good Practice Recommendations To consider the discussing the subject of ageing, death and dying and establish individual wishes. To continue to properly introduce the person centred planning model. The organisation should keep the current staffing levels under review to ensure that the individual needs of residents can be met. Take whatever action is necessary to address the uneven floorboards on the landing. Action should be taken to monitor the hot water temperature in the kitchen to ensure that it reaches a sufficient temperature to wash dishes. The programme of refurbishment should be continued to ensure that residents live in a well-maintained and comfortable environment. 3. YA33 4. 5. YA24 YA30 6. YA24 Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mimosa DS0000064017.V339655.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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