Inspection on 21/01/08 for Mulberry House

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mulberry House 28/07/06

Mulberry House 29/01/06

Mulberry House 27/06/05

Mulberry House 15/10/04

Mulberry House 08/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Mulberry House 98 Tower Road North Warmley South Glos BS30 8XN Lead Inspector Paula Cordell Unannounced Inspection 21 January 2008 09:45 st DS0000003391.V354298.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 DS0000003391.V354298.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. DS0000003391.V354298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mulberry House Address 98 Tower Road North Warmley South Glos BS30 8XN 0117 961 4657 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Julie Dawn Egan Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places DS0000003391.V354298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to persons of either gender whose primary care needs on admission to the home are within the following categories: Learning disability - (Code LD) 2. Learning disability - over the age of 65 years - (Code LD(E)) The maximum number of service users who can be accommodated is 6. Date of last inspection 28th July 2006 Brief Description of the Service: Mulberry House is one of several homes operated by Aspects and Milestones Trust. The home provides personal care and support for up to 6 adults with learning disabilities and may accommodate residents over 65 years of age. The home is managed by Mrs Julie Egan There are currently five male service users living at the home and one vacant bed. Mulberry House is located within a residential area of Warmley on a main road and bus route. Shops, including a pharmacy and post office are within half a mile from the home. A Community Centre is located within walking distance. The home has an eight-seater vehicle that has been adapted with lower steps and handrail. The premises comprise a detached house on two floors with 6 single bedrooms. There is one bedroom on the ground floor. Bathroom and toilet facilities are situated on both floors. There is a large well-maintained garden to the rear of the property. The fees at the time of publishing this report were £1180.20 to £1,206.16. DS0000003391.V354298.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection following a follow up visit that was completed in January 2007. A further visit was conducted in July 2007 but no report was completed due to a period of absence of the visiting inspector. The purpose of the visit was to review the progress to the requirements and recommendations from the visit in January 2007. In addition to checking on the welfare of the people who use the service, ensuring the premises are well maintained and to examine health and safety procedures. Prior to the visit some time was spent examining documentation accumulated since the previous inspection. This included the annual quality assurance assessment completed by the manager, monthly provider visits and reports of incidences that affect the wellbeing of the individuals living in the home (Regulation 37’s). This assisted with the planning for this visit. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from individuals living in the home and the staff supporting them. The visit was conducted over five hours. What the service does well: Mulberry House provides a comfortable and homely environment for the people it supports. There was good evidence that person centred planning was being implemented in the home. Individuals were encouraged to lead very active lifestyles making full use of the community. A cohesive and competent team of staff supports individuals. DS0000003391.V354298.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. DS0000003391.V354298.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 DS0000003391.V354298.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is available to the individuals living at Mulberry House. Individuals can be confident that their assessed care needs are being met. Individuals do not benefit from an open and transparent service in terms of their contract as additional fees and charges that may affect them, are not included. DS0000003391.V354298.R01.S.doc Version 5.2 Page 9 EVIDENCE: There was a statement of purpose that was clearly written and included relevant information to enable individuals to choose to live at Mulberry House. This met with the legislation and National Minimum Standards. Copies of the statement of purpose and contracts were seen in care files for the individuals along with the service user guide. The service user guide included pictures and was written in plain English making it more accessible to the people living in the home. The statement of purpose clearly describes the assessment process and the need for potential individuals to “test drive” the home. The home has an established group of people who have lived in the home since it first opened. The home has one vacancy. There was a clear criteria that the home can use to shortlist prospective people who may choose to live in Mulberry House. From talking with the staff and looking at records it is evident that the individuals are getting on much better with each other. The home has involved other professionals to support them in achieving this. Three members of staff stated the present manager has done much work since being in post. This has meant that there is a more consistent and cohesive team to support the individuals with a more relaxed atmosphere being achieved. Care files included copies of the home’s contract. This did not include what was not included in the fees for example aromatherapy and the contribution towards the running costs of the vehicle. Each person pays a monthly contribution towards the lease of the minibus and petrol based on usage. The amounts varied depending on the rate of Disability Living Allowance and need for the specialist vehicle. Whilst this was recorded in the home’s vehicle policy it would be more transparent if included on the home’s contract. DS0000003391.V354298.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals care needs are being met in a person centred way. Individuals are assured their safety using a risk assessment framework. This does not limit individuals but encourages the individuals to be as independent as possible. DS0000003391.V354298.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were looked at as a means of determining the processes the home goes through to support the individuals living at Mulberry House. Care plans detailed the support needs of the individuals focusing on life skills and personal care. From reading the information in each person’s care file it was evident that a person centred approach was being adopted. Plans were clearly written and included all aspects of daily living. These had been kept under review by the home. The manager stated that since she has been in post placing authorities have reviewed four of the five individuals. However one person has not had a formal social service’s review since 1995. From the records seen it was evident that the manager was requesting this with the appropriate local authority and had requested a copy of the original assessment and care plan as this had long since been archived. The home operates a key worker system where individuals are allocated a specific named member of staff to support them. One of the key workers responsibilities is to conduct a one to one meeting with the individuals to review the care and plan activities for the forth-coming month. This is good practice. Risk assessments were in place and covered a wide range of activities both in the home and the community. It was evident that the risk assessment process did not limit the individual but encouraged independence. Individuals are encouraged to take an active part in the running of the home including monthly house meetings and the involvement in the recruitment of staff. This was evidenced through conversations with staff and documentation. Individuals living in the home use various methods to communicate including makaton (sign language for pole with a learning disability) but mainly this is very individual. Care plans included how the person communicates and staff have attended training in makaton. The staff in the home have developed pictorial care plans for the individuals and some of the policies and procedures have been made more accessible. This is good practice. DS0000003391.V354298.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): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals have good access to the community and take part in meaningful activities. Individuals are encouraged to participate in everyday running of the home. Individuals have a varied and healthy diet. Individual’s preferences are catered for. DS0000003391.V354298.R01.S.doc Version 5.2 Page 13 EVIDENCE: Individuals have a structured day care plan included access to college courses and external day care. On the day of the visit two-day care staff were supporting one of the individuals to access the community. Staff stated that the individuals are given opportunities to go out in the Community. The home has a minibus, which is funded by the individuals. Each afternoon individuals are asked what they would like to do the following day. The information was available in a picture format to enable the individuals to make the choice. Included in the documentation was the reasons why the activity was cancelled, which may be the individual did not want to go out, lack of drivers or the minibus was in for repairs. It was evident that the manager monitored this closely as part of a quality assurance measure. Other activities included going out to the shops, meals out, theatre, swimming and places of interest. Some of the individuals attend a social club for people with a learning disability. On previous visits it was noted that two of the individuals preferred to spend time in the privacy of their bedroom. However, the manager and staff consulted with during this visit stated the individuals would spend more time in the communal areas of the home. Activities include arts and crafts, puzzles, listening to music, reading with staff and watching television. One of the individuals was observed assisting with lunch and laying the table. The manager stated that the conservatory now has a quiet corner for individuals to watch television. Some of the individuals have televisions and music centres in their bedrooms. Family contact was not discussed during this visit. Previous visits confirmed that individuals are supported to maintain friendships and relationships with relatives. The service guide included the rights of the people living in the home. It was evident from talking with staff that they were aware of the needs of the individuals. Staff spoke positively about the individuals living in the home. Menus were seen and demonstrated that individuals have a healthy and varied diet based on their likes and dislikes. Cupboards were well stocked. Individuals were observed requesting drinks and staff responding appropriately to the request. Breakfast was leisurely with individuals coming to the dining room at different times once their morning routine had been completed. DS0000003391.V354298.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 good. This judgement has been made using available evidence including a visit to this service. Individuals can be assured that their personal and health care needs are being met. The home acts upon the advice of the community learning disability team and this has benefited the individuals living in the home with the team being much more consistent. Individuals are protected by the home’s medication systems. DS0000003391.V354298.R01.S.doc Version 5.2 Page 15 EVIDENCE: Care plans evidenced that individual’s personal and health care needs were being met. Since the last visit the staff and the manager have developed health action plans which details the support needs of the individuals to ensure they stay healthy. This includes what support is required to attend health appointments. Evidence was provided that individuals are supported to see appropriate health care professionals including a GP, dentist and opticians. In addition the individuals have had access to members of the Community Learning Disability Team including speech and language, occupational therapist, psychology and a consultant psychiatrist to compliment the skills of the team working at Mulberry House. From talking with staff and the manager it has been evident that some of the individuals have benefited from the support from the community learning disability team in respect of behaviours that challenge. All staff spoken with stated that since the manager has been in post there has been a remarkable change in the atmosphere in the home, which has impacted on the behaviours that had been previously exhibited. This was confirmed in care documentation and from observations on the environment, which was more homely in appearance. Individuals were being supported in a respectful and sensitive manner. It was evident that the individuals in the home could choose when to get up and go to bed. This was evidenced via care documentation, observation and through conversations with staff. Medication was stored, recorded and administered appropriately. Staff had attended training with the local pharmacy and a community learning disability nurse had completed training specific to epilepsy and the treatment of a seizure. In addition the manager completes competence checks on the safe administration of medication annually. An overview was maintained on when the member of staff was due for their annual competence check. The manager has addressed a recommendation from the random visit in January 2007 to ensure that “as and when” required medication profiles are dated and signed with a clear link to these being kept under review. Staff have received training in first aid, pressure area care, epilepsy, care of the older person, dementia and autism to name a few. From talking with the manager it was evident that training was planned according to the needs of the individuals living in the home. DS0000003391.V354298.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 good. This judgement has been made using available evidence including a visit to this service. Individuals can be confident that their concerns are listened and acted upon. Good systems are in place to ensure the safety of the people living in the home. EVIDENCE: The home has policies in relation to complaints, whistle blowing, bullying and harassment and safeguarding adults. The files were accessible and numbered to enable staff to find information quickly. The home maintains a record of complaints. This included information about the complaint, the action taken to address the concerns and the outcome. There has been one complaint since the last visit from a neighbour in relation to noise. The manager stated that whilst this is ongoing due to the individuals living in the home direct communication with the neighbour has assisted in this being alleviated and improving relationships. Evidence was provided through the monthly key worker and house meetings that individuals were consulted about the care that is provided. Staff stated that although the individuals have limited communication skills they would not do something that they did not want to do and individuals can get their needs across when they are both happy and unhappy. From talking with staff it was evident that they had a good understanding of the individuals living in the home and would respond appropriately to what was communicated to them. DS0000003391.V354298.R01.S.doc Version 5.2 Page 17 Staff have attended training in safeguarding and this is on a three-year rolling programme. In addition this is covered in the Learning Disability Qualification that all newly appointed staff complete as part of their induction. The home has clear financial procedures to ensure that individual’s monies are protected. Finances were checked at regular intervals by the care staff and during regulation 26 visits. The financial department complete regular audits to ensure good practices are adopted. The manager is the appointee, and all individuals have their own bank account. People had an inventory of their belongings and these had been updated at Christmas. This is good practice and further demonstrated that the home ensures the safety of the person’s possessions. The home has strategies for supporting individuals who may become distressed and whose behaviours challenge. These had been kept under review. Since the last visit staff have completed a training package called “Sharing the Challenge” to enable them to positively support individuals living in the home. Staff stated that the incidents of aggression has been greatly reduced with staff being more cohesive and consistent in their approach. Through observations it was evident that the individuals were more relaxed than on previous visits. One member of staff stated that due to the improved management and better atmosphere between staff this has had a positive impact on the people living in the home. DS0000003391.V354298.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): 24-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mulberry House provides a comfortable, homely and clean place to live. This would be enhanced if decorating were undertaken to the hallway and communal areas in the home. EVIDENCE: Mulberry House is a detached property spread over two floors. It is in keeping with the local neighbourhood. There is a large secure garden to the rear of the property and the manager was keen to share plans for this space to more accessible to individuals. The manager stated that the path in the rear garden is uneven and is a potential trip hazard and the plan was for this to be addressed. Entry to the home is via a keypad system. This was clearly documented in a risk assessment. However, to ensure that this is transparent it should be included in the statement of purpose. DS0000003391.V354298.R01.S.doc Version 5.2 Page 19 Individuals each have a bedroom, which has been personalised and decorated to accommodate the taste of the individual. Some of the bedrooms and the bathrooms have been redecorated. It was noted that a chest of drawers in one of the bedrooms was broken and the wardrobe was looking tired. The manager said that the individual did not have sufficient funds to replace it. It is the responsibility of the provider to ensure that furniture is in a good state of repair and this must be replaced. The manager stated that a request to the maintenance department has been made for the hallways and communal areas to be redecorated. No date has been confirmed. New flooring throughout the communal areas is now in place. The home has demonstrated compliance to previous environmental requirements. In addition the home has addressed the issue of ensuring toilet rolls and hand towels are available in toilets. This has included toilet roll dispensers and a hand dryer. This is good practice. Areas of the home have been made more homely with the introduction of pictures. The manager stated that this has been due to one of the individual being more settled and is not pulling pictures of the wall. Whilst the kitchen is functional, worktops and the units are looking tired and it would be recommended that a plan to refurbish this area be devised over the next twelve months. The home has a number of aids and adaptations to meet the needs of the individuals including a walk in shower and a bath chair. The home was clean and free from odour. The home has recently achieved a four out of five star rating from a visiting environmental health officer in August 2007. There were good systems for infection control as seen at the last inspection Sluice facilities and separate laundry facilities are sited separate from the kitchen. Staff stated that the washing machines are in constant use but felt that that they were adequate for the size of home and the number of occupants. Since the last key inspection in July 2006 the manager has relocated the office to the ground floor. Staff stated that this has improved access to information and it was evident that the individuals living in the home had more access to staff. DS0000003391.V354298.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): 32,34,35,36, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A cohesive and competent staff team support the individuals living at Mulberry House. Staff have relevant training to complete their roles in supporting the people in the home. Good communication between the team and the manager ensures a consistent approach. DS0000003391.V354298.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home is staffed according to the statement of purpose and the needs of the individuals living in the Mulberry House. There is usually a minimum of two staff working in the home during the day and evening and one member of staff providing waking in night cover. It was noted that during the week there was usually three staff working in the home to enable the individuals to go out and about. The manager stated that Monday to Friday the home is busy with a more relaxed atmosphere during the weekend, although individuals are supported to go out still. Recruitment information was seen for three staff. It was noted that for two of three staff that this information was complete demonstrating a thorough recruitment process had been undertaken. The third person’s was a transfer from another home but the previous role was not of carer. The references and application seen was for the previous role. The manager contacted the Personnel Department said they would forward the appropriate documentation. The manager stated that she had seen an application for this person in respect of the role of carer at Hillsborough House. The manager stated that the home has only one vacancy now and she is actively trying to ensure that a full establishment of staff is in place. Individuals living in the home are involved in the recruitment process and an activity is organised for interviewees to complete with the individuals in the home. The manager has devised a recruitment file containing information on how the individuals can be included and the expectations of how the information is recorded. This is good practice. Staff files seen demonstrated that all staff complete an in-house induction on the care practices and the running of the home in addition to the Learning Disability Qualification. Staff training files provided evidence that there was a good rolling programme of training based on the needs of the people living in the home. In response to a recommendation the home has developed an annual training. The manager stated that is devised on the needs of the team and individual staff ‘s annual performance reviews. As part of this annual action training plan staff will attend a course on Equalities and Diversity. From conversations with the manager it was evident that the home has exceeded the government target of 50 of the workforce having a National Vocational Qualification. All staff have either completed or in the process of completing an NVQ 3 in care. DS0000003391.V354298.R01.S.doc Version 5.2 Page 22 It was evident from conversations with staff that there were good support mechanisms in place including daily handovers, monthly team meetings, staff one to one supervisions and annual appraisals. This was confirmed in documentation. The manager said that she organises three monthly teambuilding exercises away from the home, which include an extended team meeting and an element of training. Staff described a cohesive team led by an efficient manager. It was evident that the staff had built positive relationships with each other and the people living in the home. Staff clearly described the care needs of the people living at Mulberry house and how they were supporting them. DS0000003391.V354298.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mulberry House is a well managed home which strives to provide a good quality service in a safe environment. DS0000003391.V354298.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs Julie Egan is the registered manager. She has been in post since November 2006. She is a dual registered nurse completing both her general and Learning Disability Nursing Qualification. She has completed the Registered Managers Award and is an NVQ Assessor. Mrs Egan has many years experience in managing services for people with a learning disability. From talking with staff it was evident that there is an “open door” approach to management. There is evidently supernumerary hours built in to the staff rota, which is shared between the manager and the assistant home manager. Both take an active role in the management of the home. From conversations with staff and the manager it was evident that the manager had “a hands on role” and would work at weekends to ensure that the home continues to run smoothly. It was evident that the manager empowers both the staff and the individuals living at Mulberry House. The manager stated that the provider visits on a monthly basis to complete a quality monitoring visit in respect of regulation 26. Copies are sent to the Commission for Social Care Inspection. Questionnaires are sent to people who use the service, relatives and staff enabling them to express the views on the quality of the care provided. There is a business and training plan in place. From reviewing the information it was evident that the manager is pro-active in developing the service. Good health and safety systems were in place. Risk assessments were in place for fire, COSSH, manual handling and food safety. These had been kept under review and ensured safe working practices were in place. There was a good response to repairs. Audits were being completed on the environment. Checks were being completed in respect of fire and electrical appliances. DS0000003391.V354298.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X DS0000003391.V354298.R01.S.doc Version 5.2 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 YA5 Regulation 5 (a) Requirement For the contracts to be expanded to detail any extras that the individuals pay for example aromatherapy and transport costs. For the hallways and communal areas to be redecorated. For the provider to replace wardrobe and the chest of drawers in room 10. Timescale for action 21/03/08 2. 3. YA24 YA26 23 (2) (b) 16 (2) (c) 21/04/08 21/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000003391.V354298.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000003391.V354298.R01.S.doc Version 5.2 Page 28 - 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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