Inspection on 22/02/07 for Morris House

This inspection was carried out on 22nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Morris House 26/01/09

Morris House 12/02/08

Morris House 04/10/07

Morris House 05/10/05

Morris House 18/05/05

Morris House 29/09/04

Morris House 22/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Morris House Grange Farm Drive Kings Norton Birmingham West Midlands B38 8EJ Lead Inspector Jane Rumble Unannounced Inspection 22nd February 2007 09:30 Morris House DS0000016892.V324175.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 Morris House DS0000016892.V324175.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. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Morris House Address Grange Farm Drive Kings Norton Birmingham West Midlands B38 8EJ 0121 459 1303 F/P 0121 459 1303 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) Morris House Limited Catherine Dowe Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 5th October 2005 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 DS0000016892.V324175.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit took place in a day between 10 am and 6.15 pm. Prior to the fieldwork visit a range of information was gathered to include include notifications received from the home. Six people were living at the home at the time of this visit and the inspector had the opportunity to meet and talk to all six people throughout the day, talk to staff and the manager as well as observing care practice, interactions and support that residents received from staff. Care records of the two people were inspected to see what care they got. Health and safety records and staff files were also examined. The management of medication was reviewed and a partial tour of the premises took place What the service does well: The service is good at ensuring that residents are involved in making their own decisions about their own lives with support as needed. Residents living at the home said that they liked living at the home. Residents have the opportunity to take part in a wide range of leisure and recreational activities within the local community so that they experience a meaningful lifestyle. The home offers residents transport so that they can access the community and take part in activities of their choice regularly. Residents are offered a healthy well balanced diet that meets their individual needs and promotes their health. Residents are supported by a competent staff team that know residents well so their needs are met. Residents commented that staff are nice and that like them. Recruitment procedures are robust so that residents are safeguarded from harm. Residents are supported to have personal relationships so that the quality of their life is enhanced. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have available to them information about the home that would enable to make an informed choice about whether they wanted to live there. EVIDENCE: There have not been any new admissions to the home for a number of years and currently there are no vacancies at the home therefore the standards were not fully assessed. There is an admission procedure available to enable staff assess any future prospective resident to see if the home would be able to meet their needs and aspirations and this includes trial visits. Information is available to existing and prospective residents that tell them about the home and the terms and conditions of their stay. However this information is only available in a written format and would benefit from being produced in a style that is more accessible to all the people living at the home. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 9 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, 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Risk assessments need further development to ensure that risk to residents are managed in a safe and responsible manner and that staff have enough information to manage these risk. Care plans need to include specific information to guide staff to meet residents needs consistently. Residents are supported to make decisions about their own lives to enhance their independence. EVIDENCE: Each resident has a care plan, this is an individualised plan about what a person is able to do independently and should state what help is needed from staff in order for the person to have their needs met. The care plans sampled at the time of the visit needed further development so that staff had clear guidance about how to meet specific care needs consistently. Guidelines for staff to enable them support individuals when they were displaying difficult to manage behaviour described why the behaviour might be occurring rather than Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 10 what actions staff need to take to support the person. It is pleasing that care plans do include information about individual residents’ likes and dislikes to assist staff to provide care in a way that meets their expectations and preferences. At the time of this visit there was no evidence that residents had been involved or consulted about what was in their care plan and it was not produced in a style that was accessible to them. However the manager stated that she had just got information on person centred planning and would be starting to develop these with individual residents. A person centred plan is an individual plan, written by or with the person and includes information about their needs and aspirations. Care plans are reviewed periodically. When a review occurs the files sampled just recorded the date and signature of one person and typically the comment “ongoing”. This does not demonstrate that the resident and others who know the person well have, for example family members, advocates and college staff and key workers been involved in the review. Risk assessments are completed for activities that residents take part in to ensure that that consideration is given to supporting residents to take responsible risk and so promote their independence. The risk assessments sampled at this visit require further work to demonstrate that staff have accurate information about the control measures to enable them to manage risk in a responsible way. For example: • • A risk assessment for one person stated that the person was not at risk of self-harming. However, other documents state that a known behaviour of this person is banging their head against windows and furniture. One risk assessment said that the control measure was to ensure that staff observed the person constantly. This does not give staff enough guidance to keep this person safe and should include the detail of the distance that the observations should be made and clarification of their frequency. Residents are supported to make decisions about their lives. A monthly residents meeting takes place. Records of these meeting and discussions with residents show that residents are consulted on the food they eat, activities they take part in and choosing holiday destinations. Staff were observed taking time to talk to residents about what was available and their preferences for the day. Resident said that they could choose what time they go to bed and what time they get up. It was disappointing given how much effort staff place on supporting individuals to make choices that the a record was seen that stated that residents were not able to eat or drink in the lounge. There was no evidence of consultation with residents about this restriction. On discussion with the Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 11 manager it was evident that this directive had been made to protect the new furniture from soiling. This is not respecting that this is the residents home and the decision should be reviewed. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported to have opportunities for leisure and personal development so that they live fulfilling lives outside of and within the home. Residents are supported to have meaningful personal, family and sexual relationships so that their self-esteem is enhanced. Residents are offered a varied and healthy diet that meets their needs. EVIDENCE: Each resident has a weekly timetable of activities that includes planned activities such as attending college, employment preparation units and leisure activities such as going out to pubs, restaurants, shopping, ten pin bowling and the cinema. A record is made of the activities individual residents take apart in. These records need to be further developed so they include details of whether the activity was enjoyed, what was successful or not so successful about the activity so that future activity planning is informed. A weekly budget is Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 13 available to meet the cost of the majority of residents activities, this means that they are able to participate in a wide range of activities regularly. There is a pet cat, which sleeps in its own bed within the lounge area. Two cars are available to residents to support them take part in activities. It is pleasing that the organisation provides these cars and meets the cost of these as part of the weekly fee to residents. A system has been introduced where staff get a detailed induction about the specific cars prior to them being able to drive them. This ensures that staff are knowledge and competent about the vehicle before using them and protects residents from the risk of harm. One resident said to the inspector that they “like going out independently and staff helped him plan where he wanted to go and how to get there. “ A reiki therapist is employed so that residents have regular access to alternative therapies which they all commented that they enjoyed and felt was helpful to them in maintaining a sense of wellbeing. There are a number of leisure activities also available within the home including Sky television, DVD’s, videos, music and books. Residents are also encouraged to take part in domestic activities so that they can develop their independent living skills. These opportunities could be further developed. For example resident’s toast and sandwiches were observed to make for them by staff. One resident said, “They do this because it is quicker than us doing it.” Discussion with residents and staff confirmed that at times the do have the opportunity to participate in preparing their own food. Consideration should be given to making these opportunities available more consistently. The home has gone ‘green’ and residents were enthusiastic about the recycling that they are involved with. There is a small well-maintained garden the day before the inspection one resident had being supported by a member of staff to remove a tree. Another resident was enthusiastic about participating in the garden and was looking forward to planting some flowers. Menus were observed to meet healthy eating guidelines, offer variety and meet residents special dietary needs. These menus were in large print and displayed throughout the home. Residents spoken to knew what the choice of meals was for the day. The home has recently introduced theme nights where residents have the opportunity to try food from different countries. Two residents said that that they would like to have spicy food more frequently. This was discussed with the manager who agreed to ensure that this opportunity was made available. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents receive their medication safely and as prescribed by the medical officer. Generally resident’s health care needs are recognised and responded to ensuring that their health is promoted. EVIDENCE: A monitored dosage system of medication administration is implemented. Medication was stored securely in a locked cupboard within the staff sleeping in room. The medication administration record was well maintained and evidenced that resident received their medication as prescribed. They would benefit from being amended to reflect residents allergies and stating the maximum number of “as required “tablets that can be safely given within a 24 hour period. One resident is supported within a risk assessment framework to self-administer their own Insulin. Homely remedies are available and it is pleasing that the person’s doctor has confirmed that the medicine is safe for the resident to use. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 15 Residents are supported to access health care professionals to meet their individual needs. Where residents refuse to attend appointments then a record that the opportunity was offered and refused should be made. A resident was observed to be given support and guidance about stopping smoking. She said that she wanted to stop smoking because of the effects it had on her health. As yet health action plans (HAP) have not been developed. A health action plan is an individual plan that identified what support the person needs to stay healthy. It is an initiative from the white paper ‘valuing people’ and aims to keep people with a learning disability well and accessing community health care facilities the same as others of a similar age, gender and culture. Consideration should be given to use pictures within these HAP to make them more easily understood. The home employs a mix of staff that reflects the gender and culture of the people living in the home so residents can chose who they want to support them with their personal care. In 2002 one person’s records show that the clinical psychologist recommended that he would benefit from Internet access so that supervised searches of his travel could be made. It is disappointing that this recommendation remains unmet some years later. Ok health checks on residents are done and these are reviewed periodically. It was observed that staff had identified that one resident frequently had a cough when eating and drinking, staff were aware of the need to cut food up to reduce the risk of choking. But no investigation of these symptoms had been made. A referral to a speech and language therapist must be made for a swallowing assessment. Interactions between staff and residents observed on the day were entirely positive and respectful. Care plans need to be further developed so that they contain specific guidance to staff to enable them meet needs consistently Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Generally the arrangements for residents to comment on the service are satisfactory and ensure residents feel confident that their views are listened to and acted upon. Staff have the knowledge and skills they need to protect residents from harm. EVIDENCE: A written complaints procedure is available, however like other information in the home for residents it needs further work to be more accessible to them. The procedure needed minor amendment to reflect that a person can come directly to the Commission if they are unhappy with the service. Since the last inspection the home informed the Commission that a family member had made a complaint about her sons care. It was disappointing that there was no record of this complaint within the complaints log to evidence how this had been responded to . CSCI have not received any concerns, complaints or allegations about the service since the last visit. Residents were able to confirm whom they would speak to if they were not happy about something and felt confident that staff listened to them. One resident said” I would talk to any of the staff if I was not happy.” Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 17 Staff records show that most staff have had training in the protection of vulnerable adults and have clear procedures to follow. Staff spoken to were aware of the procedure to be followed in the event an allegation was made so that residents would be safeguarded from harm. The reasons for individual residents displaying physically or verbally behaviour are well understood by staff. The guidance for them to follow is unclear and needs revision to include the specific actions staff need to take. The threat of police action in some circumstances may be seen as punitive and should be reviewed. The home has a physical intervention policy but the inspector was informed that restraint was not currently used in the home. Policies and procedures for managing residents personal money was robust and protected residents from the risk of harm. Receipts are obtained for all expenditure and staff check the balance of money held each day to ensure it is accurate. One resident is supported to manage his own money and this is seen as supporting him to develop his independence. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 and 30 Quality in this outcome area adequate This judgement has been made using available evidence including a visit to this service. Residents live in a clean, tidy well personalised home that meets their needs and reflects their taste and interest. Some maintenance issues need attention to ensure that the home continues to provide a safe and homely environment. EVIDENCE: The home is a domestic style property that provides six single occupancy bedrooms some of which have an ensuite w.c. on the ground floor there is a staff office and sleep in room, two bedrooms a bathroom, kitchen, utility area lounge and conservatory that are used as a dinning area. The first floor comprises of four bedrooms, bathroom with w.c and shower room. The first floor is accessed via a stairway and residents would need to be mobile to access rooms on this floor. There are currently no aids or adaptations in the home to support individuals with poor mobility. As residents needs change due the aging process this will need to be reconsidered. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 19 There is a well-maintained and secure garden, which residents said that they enjoy in the warmer months. Communal areas and bedrooms sampled were well personalised and reflected the taste, interest and culture of the people living here. The following areas will need addressing to ensure that the home continues to provide a pleasant and safe environment for the people living here. • • • • • • • • • The kitchen is in need of refurbishment as the worktop’s are chipped and need replacing to manage infection control risk. Kitchen units are worn and need replacing. The cooker is domestic in size, given that staff dine with residents to enhance the social aspects of mealtimes consideration should be given to providing a larger cooker. The wallpaper in the lounge needs replacing as it is peeling off in places. There is inadequate comfortable seating in the lounge for residents and staff to sit together. The conservatory needs curtains or window covering so that the privacy of residents is maintained. The conservatory would benefit from a fan being installed so that a comfortable temperature can be maintained in hot weather. The curtain on the stairs window needs replacing. The stairs carpet is beginning to wear and needs replacing to avoid the risk of trips. The home manager audits the environment monthly and many of the areas` identified above have been reported to the organisation as needing attention. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported by a stable and competent staff team who know them well so that their needs are well met. Robust recruitment practices make sure residents are protected from harm. EVIDENCE: The home benefits from a well-established team with no new staff being recruited for some time, as a result staff know how to support residents well. Residents all spoke positively about the staff team for example, “staff are nice,” “staff are kind “ and “ I like x”. Throughout the inspection staff interactions with residents were positive and friendly. A key worker system is operated, this is where a member of staff is allocated to support the resident and help them with specific activities such as personal shopping. Residents all knew who their key worker was and were able to talk about the things they did with them. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 21 In addition to care staff a Reiki therapist is employed who supports residents individually with issues relevant to them, for example anger management. This person has worked at the home for a number of years and clearly had a positive regard for the residents. When he is not working as a therapist he is employed as a team leader. The staff rota showed that there is the right number of staff on duty to support residents. There are three staff on duty during the day and one awake and one sleep in person on during the night. It was observed that the shift covered is 8am to 8pm. This is disappointing, as it does not encourage residents to participate in evening activities similar to others of a same age and culture. The manager said that if residents want to go in the evening then she would arrange for additional staffing to support this. However, this does not enable residents to be spontaneous in their chosen activities. One resident said during the inspection that“ she would like to go out more in the evening. Recruitments records for the staff employed were sampled; these showed that the home uses robust procedures to make sure that they only employ people that are suitable to work with vulnerable adults. New staff receive an induction so that they have the basics skills needed to do their job. In addition staff have the opportunity to train towards completing the Learning Disability Award Framework, (LDAF) so that they have the skills and knowledge to work with residents. Staff files sampled show that they get training to enable them support residents successfully. It was not possible to see if all staff had all relevant training, as a matrix of staff training was not available. The home must ensure that all staff receive training in meeting the collective and individual needs of residents. Some staff have not had supervision regularly so that they can receive feed back on how they are working with individuals and any further training needs identified. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a home that is well run so that their views are listened to. Generally the arrangements for health and safety are adequate to make sure residents are protected from harm. EVIDENCE: The home completes a number of checks regularly to make sure that the health and safety of residents is maintained. On the day of inspection it was observed that the date that the gas safety testing date had elapsed and needed retesting to make sure that the equipment was still safe to use. The manager said she was aware that this was out of date and had contacted the organisations head office to resolve this matter. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 23 A quality assurance system has been implemented since the last visit so that it can monitor its own performance and assure that the service benefits from continuous development. In addition a representative from the organisation visits the home monthly and reports in writing on its conduct. Residents spoken with all felt that staff listened to their views and staff were responsive to them. Staff spoken to were clear about their role and the lines of accountability. Staff and residents both commented that the manager was supportive and run the home in the best interest of residents. Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Morris House DS0000016892.V324175.R01.S.doc Version 5.2 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. Standard YA19 YA6 YA42 Regulation 15(1) Requirement Residents care plans require further development so that staff have specific guidance about how to meet individuals need Timescale for action 01/04/07 2. 3. YA7 YA9 YA22 13(4) 22(1) Behaviour management guidelines need further development so that staff have clear guidance about what they need to do. The use of actions such as calling the police can be seen as punitive and must be reviewed Risk assessments must include 15/03/07 adequate control measures to minimise risk The Registered Person must 20/03/07 ensure any complaints received by the service are documented to state the action being taken and the outcome of any complaints investigation. Outstanding from 5th October 2005 The Complaints procedure should be amended to reflect that a complainant can contact the commission at any time Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 26 4. YA24 YA19 13 (b) 5. 6. YA20 YA42 YA24 YA6 13 (b) 13(2) 7. YA6 YA41 23 8 YA41 14(2) 9 10 YA36 YA19 18 12(1)(a) 11 YA14 16(2)m,n The Registered Person must ensure the recommendations of health care professionals are met. Internet access must be provided in accordance with the clinical psychologist recommendations for the benefit of residents. Where a resident is offered and refused a medical appointment a record of this must be made. As required protocols must state the maximum number of tablets that can be given in a 24 hour period Medication administration records must record residents known allergies or state none The Registered Person must ensure • Kitchen must be refurbished. • The seating in the lounge needs to be reviewed so that adequate comfortable seating is available • Stair carpet needs replacement • Secure or replace wall paper in lounge • Replace curtains on stair way Records of residents reviews must be in more detail to include names of attendees, their role, what was discussed and agreed actions Staff must receive regular supervision and a record of these supervisions must be retained A referral to speech and language therapist must be made for a swallowing assessment for one person Residents must be given the opportunity to take part in leisure and recreational activities during the evening DS0000016892.V324175.R01.S.doc 01/05/07 01/03/07 31/05/07 01/08/07 01/04/07 01/04/07 15/03/07 01/04/07 Morris House Version 5.2 Page 27 12 YA42 13(4) An up to date gas safety certificate must be obtained 20/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA22 YA1 YA8 Good Practice Recommendations It is recommended that the service user guide is revisited so that it is produced in a format accessible to residents It is recommended that the home provides residents with comprehensive, accessible understandable information, in a suitable format about its policies, procedures, activities and services It is recommended that residents are consistently given opportunities to develop their self help skills such as participating in making their breakfast and snacks. It is recommended that consideration be given to acquiring a larger cooker and a fan for the conservatory. Staff shift patterns should be reviewed so that residents have the opportunity to take part in leisure activities at the times valued by others. 3 4 5 YA8 YA24 YA33 Morris House DS0000016892.V324175.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 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 Morris House DS0000016892.V324175.R01.S.doc Version 5.2 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. 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