Inspection on 17/08/05 for Mulberry Court

This inspection was carried out on 17th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mulberry Court 25/05/07

Mulberry Court 27/09/06

Mulberry Court 21/11/05

Mulberry Court 21/02/05

Mulberry Court 21/06/04

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

CARE HOME ADULTS 18-65 Mulberry Court Common Mead Lane Gillingham Dorset SP8 4RE Lead Inspector Veronica Crowley Announced 17 August 2005 th 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. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mulberry Court Address Common Mead Lane Gillingham Dorset SP8 4RE 01747 822241 01747 822241 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) SCOPE Mr P Coe CRH 10 Category(ies) of PC, 10 registration, with number of places Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One named person (as known to the CSCI) to be accomodated in the category (LD) Learning Disability. Max number registered not to exceed Ten. Date of last inspection 21st February 2005 Brief Description of the Service: Mulberry Court provides care and accommodation for 10 people who have physical disabilities. It was registered as a new service in December 1999 to replace the accommodation at nearby Thorngrove House, where 9 of the current service users had lived for some considerable time. The service provider is SCOPE, a national ‘not for profit’ organisation for people who have a physical disability. The premises are leased from East Dorset Housing Association. Accommodation comprises one bungalow and one two-storey building, with all accommodation for service users provided at ground level. The home is within walking distance of Gillingham town centre; bus routes and the railway station are nearby. Service users at Mulberry Court live as independently as possible. Staffing is arranged to provide daily 24-hour support. The aims and philosophy of the service seek to promote the independence of service users by providing the degree of support necessary to achieve their chosen daily lifestyles, and also by providing opportunities for service users to develop skills that will support independence. A number of service users are described as having some degree of learning disability, and the Commission for Social Care Inspection has agreed a variation to the home’s conditions of registration to accommodate one person in the Learning Disability category, not exceeding 10 service users in total. All service users work at the nearby Thorngrove Garden Centre, which is also operated by SCOPE. Such attendance is not a condition of residence. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was arranged with the Manager and service users and took place during the day and evening of 17th August 2005 and throughout the day of 18th August, 2005. The inspector was new to the service and so it was considered beneficial for the inspection to be announced on this first occasion. An unannounced inspection had taken place on 21st February, 2005 establishing that service users continued to enjoy a high degree of satisfaction with the support and care provided, underpinned by a strong emphasis on equality, independence and human rights. 10 service users were being accommodated at the time of the inspection. This report will refer to service users as residents as this is their preferred means of reference. A tour of the premises took place and lunch was taken with the residents at the Thorngove Garden Centre, where all the current residents work. The inspector spoke with the Manager at length, staff on duty, an advocate and all residents during the visit. Various records were examined, including three resident’s case files. The Commission also received comment cards back from nine residents, five GP’s, four health professionals and five relatives. All responses received were discussed fully at the inspection and pertinent comments incorporated within the report. All nineteen key standards were assessed at this inspection. What the service does well: The residents at Mulberry Court enjoy excellent outcomes. The home has an effective and thorough assessment and care planning process which involves the resident fully. Staff encourage a gradual path towards independence empowering residents to make informed choices and decisions about their lives. Residents participate fully in the running of the home, including decisions about meals, housework, trips, meaningful employment and education opportunities. The home excels in ensuring good relationships inside and outside the home are maintained. They also excel in offering spontaneous choice and variety of food, catering for any special dietary needs. Care plans detail the assessed health needs of residents and records seen also demonstrated evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear, comprehensive arrangements in place to ensure resident’s medication needs are met. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 6 There are robust systems and policies in place in relation to complaints and for the protection of vulnerable adults. None had been reported in the last year demonstrating that the residents’ welfare is being protected and promoted. Mulberry Court offers a high standard of accommodation presenting a homely, comfortable yet spacious environment. The Manager and his staff team are competent and confident in their jobs and enjoy excellent relationships with the residents. Comments received from health professionals, relatives, GP’s and residents were all extremely positive. The Manager oversees and monitors the service well and is committed to training, supervision and reflective practice which ensures positive outcomes for the residents. What has improved since the last inspection? What they could do better: Policies, currently in draft, on sexuality and personal relationships should be verified and made available to staff in order for them to guide and support residents appropriately. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 7 Although SCOPE provide a comprehensive and full training programme, particularly in diversity areas, consideration should be given to race equality and anti-racism training. 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. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 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 Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 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) 2 No new residents had been admitted within the last year so this standard was difficult to assess, however by examining care files it was clear that full assessments had been undertaken ensuring the service could meet the identified needs of individuals. EVIDENCE: SCOPE has a comprehensive admission and placement policy, including a preadmission assessment. From records seen, the home had obtained a Care Management Assessment in addition to completing an in-house assessment prior to admission. This assessment identified the care hours needed to meet the residents’ needs. The records demonstrated that the resident and the residents’ family had been involved in the assessments and admission. Care plans are then developed shortly after admission with input from the resident. Those seen had also been signed by the resident agreeing to the contents. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 10 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, & 9 The care plans are comprehensive, up to date and cross-reference to action plans, demonstrating that staff are conversant with the residents changing needs and personal goals and able to support them appropriately. The systems for resident consultation in this home are good with a variety of evidence that indicates that residents’ views are sought and acted upon. Since the last inspection the home has expanded upon and included more detail in individual risk assessments ensuring greater safety for residents. EVIDENCE: Three care files were examined in detail. Care files included an up to date Care Plan and Assessment. Through discussions with residents and staff it was clear that care plans are updated every six months with full participation of residents. The care plans seen were accurate, thorough and covered all areas of personal and social support, associated health needs and a ‘working’ Action Plan. The care plans also include where specialist input is needed (i.e. physiotherapy or psychology), and how staff support residents in accessing these services. Care plans are written in the first person and set out both short term and long term goals based on the wishes and aspirations of the Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 11 residents. Evidence was seen where staff and an advocate have supported and are continuing to proactively support residents to reach their goals. Residents spoken with confirmed that they could have a copy of their care plan if they so wished. The Manager and staff are proactive in promoting the rights of residents to make decisions and control their lives. There are no limitations placed on residents in relation to their choices or human rights. This was demonstrated by speaking with the residents, staff and by examining a variety of records. Staff provide information and assistance in order to support the residents to make their own choices and decisions. Examples include providing information on holidays, clubs, mobility aids, advocacy, travel and day opportunities. All residents manage their own finances. Of the nine comment cards received five residents stated they would like to be more involved in decision making within the home. However when spoken with they could not think of any way specifically in which this could be achieved. The home are able to demonstrate a variety of ways where residents have opportunities to be involved in the running of the home. These include one to one key sessions, monthly residents meetings, where minutes demonstrated that the running of the home is consistently discussed, being representative on the panel for recruiting staff. In more general terms the residents can easily access the senior management through the open door policy operated by the Manager or by speaking with the visiting Regulation 26 visitor for the Company. The home has a comprehensive, user-focussed risk assessment policy and procedure in place. Risks are well documented and focus on enabling residents to continue to take responsible risks and maximise independence. Where, from the case files examined, risks had been identified following a needs assessment these had been duly recorded. As with care plans, risk assessments are updated every six months. Following a recommendation at the last annual inspection the home had since improved some individual risk assessments by being more detailed in the recording (i.e. stating the specifics of the support required). Residents receive support and training, where necessary, such as Health and Safety training, road safety in relation to motorised wheelchairs and buggies, and personal safety when out in the local; and wider community. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Residents are well supported to take part in meaningful, appropriate jobs and education or training opportunities in order to achieve their full potential. Links with the community are good which support and enhance residents’ social and educational opportunities. The residents enjoy excellent relationships inside and outside the home and maintain good family links which enrich their lives. The daily routines promote independence and individual choice facilitating and supporting residents to achieve their individual goals. The meals in the home are excellent offering spontaneous choice and variety and catering for any special dietary needs. EVIDENCE: All the residents living at Mulberry Court undertake voluntary work at Thorngrove Garden Centre. This Garden Centre is owned and run by SCOPE. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 13 Various opportunities are available to the residents at the Garden Centre, either working in the coffee shop/restaurant, working in the plant shop, or potting, growing and tending plants. The residents can choose how many days they work in the Garden Centre. Where residents request alternative work placements or educational opportunities their key-workers support them by contacting local agencies and employment services. Two residents currently living at Mulberry House undertake other voluntary work in the community. A number of residents also attend adult education courses at the local college (including computers and literacy). One service user at another of SCOPE’s homes in Gillingham has, with the support from the Manager, developed a ‘Community File’ which describes all the local facilities in the area with accompanying photographs. The residents spoken with were fully aware of the local activities and support offered by specialist organisations and confirmed that staff assist them with gaining this information (for example PHAB club, DAB club, Riding for the Disabled, Local Disability Action Group, NorDis, Lifestyles and Stepping Stones). The care plans examined demonstrated that residents participate fully in the community, that they regularly go shopping, out for day trips, to the cinema, pub and swimming. Although the majority of residents are independent and go out by themselves the home has the use of a car and a minibus to support residents in accessing community activities should they so wish. The needs of residents in relation to social and emotional well-being are very well documented and this standard is exceeded. Staff remain committed to supporting family links and friendships, but are also careful to ensure that residents determine who they see. All residents have contact and friendships with disabled and non-disabled people and are encouraged to have friends and family to visit, including for dinner and/or parties. Support plans seen provided detailed information about social contacts and significant people in the lives of residents, and daily care records included entries relating to contact with families, friends and acquaintances. Residents are free to develop and maintain intimate personal relationships, and staff support the privacy of this. The Manager reported that he and a number of residents had been involved in a working group to develop appropriate policies on sexuality and personal relationships. To date these policies have not been ratified and a recommendation is made for this to be addressed, in order for staff to guide and support residents appropriately. Each residents’ care plan sets out the agreed responsibilities in relation to housekeeping tasks. Some residents have opted out of regularly cooking and cleaning communal areas, whilst others have requested to cook the evening meals on some occasions. All residents make their own breakfasts and lunches, do their own laundry and cleaning of their bedrooms (with varying levels of support and supervision). The house rules promote independence and individual choice. All residents have keys to their bedrooms and to the Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 14 front door of the house and have unrestricted access to the communal areas and gardens. Residents confirmed that staff do not enter their rooms unless they give their permission. The menus seen confirmed that varied, balanced meals are provided. Alternative meals taken were accurately described on the menus and demonstrated where special diets are being catered for. Residents can choose where they eat their meals (either in the dining room, lounge or bedroom), although they choose to eat in the dining room for the majority of the time because they report the social interaction is good. Residents are involved in planning, preparing and cooking the meal if they choose to and all nine responses received from the comment cards confirmed that the residents like the food provided. The inspector observed breakfast and evening meal and took lunch with the residents at the Garden Centre. Staff were seen to be empowering residents to make choices, offering only minimal assistance in order for residents to gain greater autonomy. The Manager reported that currently they were piloting a new way of selecting menus to enable the process to be more spontaneous. Although the new system is in its infancy residents and staff felt it was working well. This standard is exceeded. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 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 Staff ensure consistency and continuity of support for residents through the allocation of designated key-workers, concise individual working records and partnerships with advocates, family, friends and relevant professionals. The health needs of the residents are assessed and well met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear, comprehensive arrangements being in place to ensure residents medication needs are met. EVIDENCE: Care plans demonstrated and residents confirmed that staff provide sensitive and flexible personal support in order to maximise their privacy, dignity and independence. Consistency and continuity of support is achieved through the allocation of designated key-workers and individual working records (for example the action plan) which set out preferred routines, likes and dislikes etc., Partnerships are also facilitated with advocates, family, friends and relevant professionals, subject to the residents’ consent. Residents confirmed that they enjoy a flexible approach to when they go to bed, get up, when they bathe or partake in activities. They are encouraged to choose their own clothes, hairstyle etc., in order to reflect their individual personalities. It is not Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 16 always possible to offer same gender support with personal or intimate tasks despite positive recruitment campaigns. The case files examined evidenced that the healthcare needs of residents are assessed and met within the home. The care plans set out the support needed to meet their needs. Although some residents are independent in accessing the doctor/dentists/optician others require some staff support. Any support offered is arranged with the focus on enabling residents to be as independent as possible, therefore support ranges from prompting to actually supervising and attending with the resident. Care files examined demonstrated that staff have made referrals to a variety of professionals on behalf of the residents. Residents have a choice of GP, although they all attend the local village surgery. Comment cards received from GP’s confirmed that they are able to see the residents in private and feel the care they receive at the home is good. Staff have received training in managing specific needs such as epilepsy. The home has a robust medication policy. All staff complete an induction in administering medication. This is an informal training session as part of SCOPE’s induction for new workers. A number of staff had completed a ‘Safe Handling in Medicines’ course and in addition the local Pharmacist provides specific training on medicines used in the home. Medicines are kept securely in a locked cabinet. Some medicine is stored in a dedicated fridge, where staff monitor the temperature using a maximum and minimum thermometer. Accurate records were seen of medication administered, which had been signed off by two members of staff. Staff both record and receipt administration and return of medicines. When a resident who self-administers or when a resident takes medicine out of the home this is recorded in their Individual Working Record. The staff encourage and support residents to retain and administer their own medication, following a multi-disciplinary risk assessment. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 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 The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. Robust systems and effective adult protection training ensures that residents are protected from abuse and that their welfare is being promoted. EVIDENCE: Observations made during the inspection clearly demonstrated that the views of the residents are listened to and acted upon. Further evidence of this was found in the minutes of house meetings and in Individual Working Records. All the residents spoken with knew who they could complain to, and were confident that any complaints would be addressed fairly. Information on how to complain is detailed in the homes ‘Statement of Purpose’, in the ‘Service User Guide’ and in a leaflet given to residents entitled ‘Complaining isn’t wrong – it’s a Right. There is also a notice on the residents notice board informing them how to complain if they are unhappy with the service provided. SCOPE also have a designated complaints officer to deal with residents/service users formal complaints. The Manager reported that no complaints had been made since the last inspection and that refresher training on ‘dealing with complaints’ was scheduled for September 2005. The comment cards received from relatives and health professionals also confirmed no complaints had been made against the home. SCOPE has robust policies and procedures in place and staff undertake regular training in relation to the protection of vulnerable adults. There is an identified adult protection officer at the Mulberry Court and an Adult Protection Team based at SCOPE’s Head Quarters. The Adult Protection Officer attends regional Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 18 conferences on best practice and key issues relating to Adult Protection. A copy of the Local Interagency ‘No Secrets’ guidance was seen at the home. The Manager reported that there had been no Adult Protection referrals since the last inspection. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 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 home is well designed, maintained and furnished to a high standard presenting the residents with a spacious, clean and homely environment. EVIDENCE: Mulberry Court is purpose built and designed to meet the needs of residents who have a physical disability. The property is owned by a housing association, who also undertake any repairs and routine maintenance. The accommodation for residents is on the ground floor with level access throughout the buildings and well designed garden. Mulberry Court comprises of two bungalows (one chalet style), accommodating five residents in each. Each bungalow has an open plan kitchen/diner, lounge, a bathroom, a shower room and two toilets. Both bungalows are furnished, decorated and maintained to a high standard. Both dining rooms had recently been painted. Records are kept of all renewals and repairs. The lounges, bedrooms and dining rooms are homely in style. Bathrooms and hallways are less domesticated, but continue to be welcoming, clean and bright. Bedrooms are all personalised which reflect individual personality. The premises are free from odours and on the days of inspection were very clean and tidy. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 20 Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 21 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) 35 The staff fulfil the aims of the home and meet the changing needs of the residents through good programmes of training and development further supported by regular supervision. EVIDENCE: SCOPE has developed an Induction and Foundation training pack for all new staff, which meet the ‘Skills for Care’ standards (previously TOPSS). The staff team not only work at Mulberry Court but also at three other community homes run by the organisation in Gillingham. SCOPE provide regular training for staff in all key areas (for example first aid, manual handling, food hygiene, adult protection, risk assessments). A training events calendar is produced annually and staff are also encouraged to undertake training courses external to this. The Manager confirmed that staff are all up to date with mandatory training and random checks on the records of four members of staff further evidenced this. The training is linked to the home’s service aims and to residents needs. For instance staff have received training in epilepsy, diabetes, disability equality and autism. In addition over 50 of the staff team hold their NVQ Level 2 award. The organisation is also funding a number of staff to undertake the NVQ level 3 award. Currently 25 of staff at Mulberry Court have a disability clearly demonstrating SCOPE’s Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 22 commitment both to issues of equality and to reinforcing positive role modelling for the residents. Each member of staff has a training needs assessment completed annually. Staff also confirmed and records seen further evidenced that staff receive regular supervision in order to enhance their skills and receive support and professional guidance. Whilst speaking with staff it came to light that although SCOPE provides excellent disability equality training there has been no race equality or antiracism training and a recommendation is made for this to be considered. All nine responses received from residents, via the comment cards, stated that the staff treated them well and that they felt well cared for. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 23 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) 39 & 42 There are robust systems in place for monitoring the performance of the home against its’ Statement of Purpose and The Care Homes Regulations to ensure residents achieve good outcomes. The health, safety and welfare of the residents is promoted and protected by a huge variety of excellent risk assessments, good monitoring and recording systems and a trained staff team. EVIDENCE: There was evidence of continuous self monitoring, involving residents. Yearly reviews are carried out with the residents and their family/ representatives / friends. This review monitors how the residents’ goals and care plans have been achieved. In addition residents are formally asked their views about the service provided to them. The results from this years’ survey demonstrated that the service was performing at 3.4 3 equalling good and 4 equalling excellent. This was slightly lower than last year and plans are to be formulated in order to address issues brought up for improvement. A staff satisfaction Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 24 survey had also been undertaken, but analysis of the findings was yet to be finalised. Regulation 26 visits are carried out monthly and copies of reports sent both to the home and to the Commission. A copy of the Annual Development Plan was also seen on the residents notice board. The residents confirmed that they are informed of any announced inspections and are encouraged to talk with inspectors. SCOPE are proactive in keeping up with all relevant guidance and legislation and any requirements or recommendations that have been made in the past have all been addressed within the agreed timescales. Examination of maintenance and safety records indicated that all checks, testing and servicing of equipment and systems were being undertaken at the recommended intervals. There is a designated staff member responsible for health and safety, fire precautions and first aid. Residents have also had training in personal safety, manual handling and food hygiene. Appropriate policies and staff guidance were in place and all staff receive training in first aid, manual handling, health and safety (including COSHH and Infection Control) and food hygiene. Risk assessments examined were being used to support safe working practices. Accidents and Incidents had been recorded accurately and appropriately and where necessary notified to the relevant agencies. Mulberry Court D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 25 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 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 x 4 3 4 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mulberry Court Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x D55 S26847 MULBERRY COURT V237504 170805 Stage 4.doc Version 1.40 Page 26 NO 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 Regulation Requirement Timescale for action 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 15.5 35.4 Good Practice Recommendations The draft policy on sexuality and personal relationships should be formailsed. Consideration should be given to providing race equality and anti-racism training. 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