CARE HOME ADULTS 18-65
Morris House Grange Farm Drive Kings Norton Birmingham B38 8EJ Lead Inspector
Joe OConnor Unannounced 18 May 2005 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 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 Stationary 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. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Morris House Address Grange Farm Drive Kings Norton Birmingham B38 8EJ 0121 459 1303 0121 459 1303 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Morris House Ltd Catherine Dowe Care home 6 Category(ies) of Younger Adults, Learning Disability registration, with number of places Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 29 September 2004 Brief Description of the Service: Morris House is a detached house situated in a residential area of Kings Norton. Morris House is registered to provide personal care and support to six adults who have a learning disability. The home is staffed twenty four hours a day including waking night and a sleeping in member of staff. The home is situated close to the local shops of Kings Norton and West Heath and is also within short walking distance to local bus routes. The home comprises of six single bedrooms, five of which have en-suite facilities. Two of the bedrooms are on the ground floor and the other four are on the first floor. The home offers a choice of bathroom or shower room. The home has a large garden that has a patio area and seating for service users. The garden benefits from outside lighting and a summerhouse. There is limited off road parking with additional parking available on the road. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The Inspector had the opportunity to talk to three service users and two members of staff. One of the staff spoken to had only been in post for over a month. Care practices were observed, interactions and support from staff. The Inspector also sampled a meal with the service users at teatime. A limited tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff training and recruitment records were also examined and a number of health and safety records were also sampled. The Inspector had opportunity to talk to the Registered Manager. What the service does well:
Service users were observed to receive friendly and professional support from care staff. Comments were received from service users that were generally very positive about life in the home. One service user commented that “staff are very good and they listen to me”. Another stated “ I like living here and can go out to see my friends by myself”. “ This home is much better than other places I’ve been in”. “ Staff gives us privacy”. Service users appeared well cared for and dressed appropriately for the climate of the day. Staff showed an awareness and understanding of the service users needs. They have completed the majority of mandatory training topics and have completed training in the safe handling of medicines. Service users have the opportunity through monthly meetings to communicate their wishes and feelings about the food provided in the home and the activities they participated in. Specific dietary requirements are catered for and this was evident when sampling one service user’s records that identified that she was a vegetarian. Service users expressed satisfaction with the meals provided in the home and the menus indicated there was a varied nutritious choice and there was a well stocked range of food stored in the cupboard, refrigerator and freezer. Transport is provided for service users to go out to the community such as the cinema, local pubs and Cannon Hill Park Nature Centre. Service users are able to spend time in the home as they please and no rigid rules or routines are present. They are also able to maintain contact with their relatives and on occasions one will stay at home for the weekend. There is a relaxed friendly atmosphere that appears to benefit the service users. They have access to local healthcare professionals such as GP, dentist, chiropodist and optician. Specialist support is available through the local Primary Care Learning Disability Trust.
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
Service users must be given consideration to having their meetings held on a more frequent basis, as there were long gaps between the last and most recent meeting. The complaints procedure is still not accessible to those service users who have difficulty reading. This is an outstanding requirement from the previous inspection. A record for complaints received and the action taken to address these was found to be up to date. It was noted that the company at the request of the CSCI had investigated a recent complaint but the outcome of the investigations was not on the complaints file. Generally the recording of medication is good. However, care is needed to ensure that the Medicines Administration Records or MAR sheets as they are known, clearly indicate where medication received has been booked in and to state where balances from the previous MAR sheets are being carried over. Homely Remedies protocols for service users were found to be in need of reviewing. The promotion of service users’ health and safety will require some improvements. Staff had yet to complete manual handling training a requirement from the previous inspection and they were also due updated training in food hygiene. Service users and staff expressed dissatisfaction with the vehicle currently in use, which they said was too small and prone to breaking down. A service user stated she had difficulty getting in and out of it. A requirement from the previous inspection for repairs to be completed had been addressed and there was evidence of an up to date MOT certificate. However, previous inspection
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 7 reports had referred to comments made by the company that a new vehicle would be purchased but so far this has not happened and action must now be taken to address this. An evacuation plan for the rear door of the vehicle had not been drawn up. This is another outstanding requirement. 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. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 The Statement of Purpose and Service User Guide have been amended to fully reflect where the National Minimum Standards are not met with regard to the physical environment. The needs of the service current user group are being met through the maintenance of detailed records and staff demonstrating an understanding of their needs. EVIDENCE: There is a Statement of Purpose and Service user Guide that had been updated since the last inspection. Amendments had been made to confirm where two of the bedrooms did not meet the National Minimum Standards spatial requirements. A request was made to the manager for a copy of the Statement of Purpose to be forwarded to the CSCI. Standard 2 was not assessed on this occasion, there were no new admissions. Service users needs were found to be met at the time of this inspection. A sample of three care plans confirmed that there were details records in place that informed staff how the needs of each individual were to be met. There was evidence to confirm that good links are maintained with specialist services such as Community Nurse, Consultant Psychiatrist and Dietician. The atmosphere in the home was found to be relaxed and three service users provided the following comments: “ It’s a nice home and I feel safe here” “ The staff will listen to me if I am worried”. “ The staff respects my privacy”. Although one service user commented “ I would like staff to take their time
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 10 explaining things to me”. Discussion with staff confirmed they had a good understanding of the needs of the current service users, who appeared to be well cared for and dressed in clothing that was appropriate to their age. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, & 9 Care plans provide a detailed picture of service users needs and how these are to be met. Service users are encouraged to make decisions about their lives through service users meetings, which need to be held more frequently. Service users have in place detailed risk assessments concerning any limitations on their independence. EVIDENCE: Each service user has a detailed care plan that covers all aspects of their daily living. Care plans sampled contained detailed information around specific therapeutic interventions to assist with those who have difficulties with their behaviour. For example a number of service users take part in tai-chi exercises to assist them in reducing their anxieties. Service users preferred form of address, likes and dislikes are recorded. Each service user has a named member of staff who is a keyworker and every three months the service user is involved in supervision with the keyworker where any changes to the care plan are made. There was evidence that service users had signed the care plans during their draft and review. Risk assessments were in place that covered topics such as managing challenging behaviour and for manual handling requirements. The manual handling assessments had been reviewed. This was a requirement from the
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 12 previous inspection. A risk assessment was in place for one service user who was managing their own administering of insulin. Guidelines were in place to inform staff of action to be taken when contacting the GP and ambulance should there be any concerns with an individual service user’s condition. Service users are encouraged to be independent and any limitations are recorded on individual risk assessments. A service user said she goes out to her daycentre independently by bus and was aware of guidelines in place of letting staff know if there were any problems or if she was going to be returning late. Service users stated that they were consulted by staff about their meals and where they would like to go out. They confirmed there were residents meetings and minutes of these were seen. However, it was noted that these did not occur on a monthly basis. Service users personal allowances were not checked during this visit although one service user stated they preferred their personal allowance to be looked after by the manager. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15,16 & 17 Service users with staff support are able to access activities in the community. The current vehicle used is not suitable in meeting the service users’ access requirements. Service users maintain good relationships with staff and have contact from relatives. There are no unnecessary restrictions affecting service users daily routine, but service users must be given the opportunity to be given a key to their bedroom. Service users have access to wholesome nutritious meals with a varied menu demonstrating choices available. EVIDENCE: Each service user has a timetable of activities during the week that includes planned activities such as day services and leisure activities including going out to pubs, restaurants and cinema. Two service users spoke about their daytime activities and stated they enjoyed attending them. One service user goes to a college and is involved in animal care and meal preparation. Another service user goes to Birmingham Industrial Therapy Association that involves some assembly and packing tasks. One service user spoke about his interest in reading and part of his timetable was to visit the local library. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 14 A mini bus is provided by the home and a number of service users and staff expressed concerns that it is too small and the windows could not be opened adequately. They also stated that it would frequently breakdown On observation it was noted that the vehicle currently being used is not suitable to transport the current group of service users and the organisation must be mindful of their responsibility under the Disability Discrimination Act 1995 to provide transport that is accessible for service users with a disability. A sample of service users records found that they are able to maintain contact with members of their family, some having home visits at the weekend. Observations at the time of this inspection indicated that there was a good relationship between the service users and staff, with no unnecessary restrictions apparent. Staff were aware of service users’ routines and these were respected. One service user stated she had a key to her bedroom but two stated they did not have one and expressed a wish to have a key to their bedroom. A holiday is being arranged for the service users to go to Spain later this summer and one service user had gone out with a member of staff to get a new passport. Service users were observed having tea, which was freshly made quorn vegetarian lasagne with salad and chips followed by a choice of cakes. The meal sampled was found to be well presented and very tasty and it was evident that all the service users were enjoying it. There is a varied and nutritious menu that is updated weekly A record is maintained of what service users had eaten Service users stated that they would be offered an alternative if they did not like what was on the menu. The refrigerator and food cupboards were found to be well stocked. One service user file sampled found that the individual had been referred for specialist support with regard to their diet due to concerns that they were overweight. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 & 20 Service users that they receive support with personal care and choose when they require assistance. Service users are able to access community and specialist primary healthcare services through good recording systems. However, work is still required to ensure service users have individual health action plans. Medication management needs to be more robust ensuring the good health of service users is promoted. EVIDENCE: There is a mixed group of service users living in the home with a gender care policy in place. Each service user has a named keyworker. Service users stated that apart from having to get up early to go out to their day services, they were able to go to bed and get up when they wanted to. A sample of the daily recording had examples of when service users had chose to have a lie in. There was also evidence of personal care tasks being completed by service users. A requirement from the last inspection was for individual health action plans to be developed in line with the Valuing People white paper. The manager stated that this had not been fully implemented and therefore the requirement remains outstanding. There was evidence from a sample of service users’ records that they have access to different professionals including a chiropodist, optician, dentist and GP. Good relationships are maintained with specialist services provided by the Primary Care Learning Disability Trust. A number of service users had recently been reviewed for their medication. Manual handling assessments were in place and these had been reviewed since
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 16 the last inspection. Service users weight is monitored every month. Medication management in the home was found to require some improvement as some medication was found not to have been signed in on the Medicines Administration Records (MAR charts) and there was evidence that the number of tablets left for one service user had not been carried over from the previous MAR chart cycle. It was noted that the supplying pharmacist had visited the home prior to this inspection and identified the need for service users’ homely remedies protocols to be reviewed and so far this had not been completed. The manager had addressed a requirement from the previous inspection for an audit stock control of boxed medication, which was found to be recorded satisfactorily. Accredited medication training has been completed by the majority of staff. Service users have written protocols in place for the use of PRN medication. A self administering of medication assessment is in place for one service user who self administers insulin. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 A complaints procedure is in place for service users but consideration must be given for in an accessible format. Service users feel staff listen to their views and concerns and these are responded to by the manager. Staff receive appropriate training in the protection of vulnerable service users backed up by appropriate policies and procedures. EVIDENCE: There is a complaints policy and procedure although the requirement from the previous inspection for a more accessible complaints format had yet to be developed. Two complaints had been made since the last inspection, one had been initially received by the CSCI. A sample of the complaints log found that the investigation and outcome of one of the complaints first had been recorded. The complaint received by the Commission had been investigated by the provider although the outcome of the complaint investigation was not recorded on the complaints log. A member of staff on duty stated that the organisation’s response was on the service user’s file but the manager must ensure a copy of the provider’s response is on the complaints file. Service users stated that they would be able to go to the manager and staff if they had any complaints. Staff training records examined found that the majority of staff had undertaken training in areas such as the abuse of vulnerable adults with learning disability, managing challenging behaviour and physical intervention. One staff member who had recently been in post for over a month was able to confirm her knowledge of the adult protection procedures, and state that she would be able to report any poor practice to the manager. There is a policy and procedure for physical intervention. This will require some
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 18 amending to state that where restraint is used in an emergency the CSCI will be notified without delay. Service users personal allowances were not examined during this inspection and will be assessed at the next visit. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The premises is maintained and cleaned to an acceptable standard. Service users are able to move freely around the home without any apparent hazards. EVIDENCE: A partial tour of the premises was undertaken at the time of this inspection. The premises was found to be clean, tidy and smelled fresh. It was evident that the manager had taken action to provide new settees and armchairs for the lounge. Service users stated that they were pleased with them and they were comfortable. The path from the summerhouse to the kitchen had been relayed. Dispensers for disposable towels had been installed in all of the bathrooms and kitchen. At the time of this inspection the manager had not obtained procedures for the control of infection from the City’s Public Health Nurse. However, the manager had addressed this after contacting them during this visit. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 & 35 Service users are supported by staff that are competent and qualified to meet their needs. Current staffing levels meet the needs of the service users providing adequate cover throughout the day with night wake and sleep in support during the night. Staff recruitment records meet the requirements of the regulations ensuring protection for the service users. There is a programme of training that enables staff to undertake their duties but updated training is required in manual handling and food hygiene. EVIDENCE: Staff demonstrated an understanding around the needs of the current service users and provided positive interactions with the service users. Three of the care staff have a qualification to NVQ Level 2 while one of the senior carers has NVQ 3. Four other members of staff are completing NVQ Level 2. The levels of staffing were found to be adequate at the time of this inspection. In discussion with the manager no staff had left employment since the last inspection. The deputy manager has been on long term sick leave and the manager was not able to give a date of when he would be returning. Two members of staff were due to leave in order to return to their home abroad. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 21 Service users are involved in the recruitment of staff and in discussion with a new member of staff it was stated that she had the opportunity to meet and get to know the service users following her interview and visited the home twice. There had been improvements with the staff recruitment records since the last inspection. Four staff files were sampled and there was CRB checks, Job application forms, job description, two references, proof of ID, personal details, photograph, staff risk assessment and medical questionnaire. However, one file only had one reference. The manager stated that new contracts for staff were being drawn up by the organisation. A record of staff training was found on staff member’s file with evidence of certificates of training courses completed and evidence of qualifications. An examination of these records found that the majority of staff had completed training in first aid, fire safety, safe handling of medicines, and abuse of vulnerable adults. There was evidence that staff had received specialist training in areas such diabetes, managing challenging behaviour, and physical intervention. Each file sampled confirmed that staff have an induction programme that is signed and dated by staff when completed. The manager stated that so far staff had yet to complete manual handling training a requirement from the previous inspection and it was noted that staff had not completed up to date training in food hygiene. Further sampling of staff records found that staff had not undertaken training towards the Learning Disability Award Framework or LDAF, as it is known this provides specific training for those staff working in the area of learning disability. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41 & 42 There is a friendly open atmosphere that service users are comfortable with. Records being maintained were generally up to date and held in a locked facility for the protection of service users. A quality assurance system must be developed in order that service users have confidence that their views will be included in the future development of the home. The health and safety of service users is promoted but some improvements are required. EVIDENCE: The atmosphere was found to be relaxed and friendly. Service users felt able to approach the manager if they had any worries or concerns. Staff stated there were staff meetings where they can raise any issues with the manager. As previously stated the only area of concerns for service users and staff was the current minibus as they felt this was too small for everyone. A representative from the organisation visits on a monthly basis and reports of these visits recorded service users and staff views. However a quality assurance system had yet to be implemented and the home must address this, as this was a requirement from the previous inspection.
Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 23 A business plan must also be made available for inspection. Records being maintained were generally up to date and locked in secure cupboard in the office. Health and safety records were examined and it was noted that there was a record of water temperatures being completed every month. The records confirmed which water outlets had been used. There were also daily temperatures in place for the refrigerators and freezers and the probing of cooked meat. There was evidence of a recent fire drill. At the time of this inspection the fire alarm and nurse call alarms were being serviced. The fire risk assessment had been reviewed since the last inspection but the format currently being used lacks detail. There was documented evidence to confirm that the gas cooker had heating system had been serviced and a current Gas Landlords Safety Certificate was in place. The main kitchen was found to be clean and tidy with appropriate coloured chopping boards. There were well stocked food cupboards with appropriate stock rotation in place. Service users currently have the use of one vehicle a white minibus. A requirement from the last inspection was for an evacuation plan to be completed for the rear door. This had not been addressed. Repairs had been completed to the rear door along with an MOT but there was no up to date record available to confirm that regular checks were being undertaken to ensure that it was in a good state of repair. It has been noted that during previous inspections assurances had been given by the provider that a replacement vehicle would be purchased but so far no progress has been made to address this. This is despite comments from service users and staff that they are dissatisfied with the size and condition of the current vehicle. Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23
ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Morris House Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x 3 2 x E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 25 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. 2. Standard 7 20 Regulation 12(3)(4) 13(2) Requirement The Registered Person must ensure service users meetings are held every month. The Registered Person must ensure that all medicines administered to service users record quantities received and balances carried over. The Registred Person must ensure that the complaints procedure is available in a suitable format for service users.- Outstanding Requirement. Timescale for 31 October 2004 not met. The Registered Person must ensure that all records, correspondence relating to complaints investigations must be held on the complaints file. The Registered Person must ensure that the procedure for physical intervention is amended to state that when restraint is used in an emergency the CSCI is notified without delay. The Registered Person must ensure that all care staff receive training in manual handling and food hygiene. Staff must also undertake training under the Timescale for action From 18/05/05 From 18/05/05 3. 22 22(1) 18/07/05 4. 22 22(1) From 18/05/05 5. 23 13(6) 18/06/05 6. 35 18(1)(c ) (i) 18/07/05 Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 26 LDAF Programme. 7. 39 24(1)(a) (b) Many of the quality assurance methods indicated by the policy are not actually in use at the home. This must be addressed.Outstanding Requirement. Timescale 31 December 2004 not met. Although the fire risk assessment has been reviewed the current format used is not detailed enough. An alternative format must be used The Registered Person must have in place an evacuation plan for the rear of the vehicle. Outstanding Requirement. Timescale 30 September 2004 not met. The Registered Person must ensure that it maintains an up to date record of vehicle checks. The white vehicle is not suitable for the current group of service users. Despite previous assurances that a new vehicle is being purchased no such action has been taken. The Registered Provider must be mindful of their responsibilites under the Disability Discrimination Act 1995 and ensure the service users have access to transport that is safe and accessible. An action plan is required stating when this will be addressed. 18/09/05 8. 42 13(4) 23(4)(v) 18/07/05 9. 42 13(4) 01/06/05 10. 11. 42 42 13(4) 13(4) From 18/05/05 18/06/05 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 19 Good Practice Recommendations In line with the Valuing People paper the home is advised to introduce health action planning for service users.
E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 27 Morris House 2. 39 & 43 Outstanding Recommendation from inspection 29 September 2004. There should be a business plan for the home and service, open to CSCI Inspection and reviewed annually. Outstanding Recommendation from inspection 29 September 2004 Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Morris House E54 S16892 Morris House V228353 180505 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
