CARE HOME ADULTS 18-65
Mulberry House 98 Tower Road North Warmley South Glos BS30 8XN Lead Inspector
Wilfried Maxfield Announced 27 June 2005 09:30 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 House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Mulberry House Address 98 Tower Road North Warmley South Glos BS30 8XN 0117 961 4657 admin@aspectsandmilestones.org.uk Aspects & Milestones Trust 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) Mrs Elva Verretta Bennett Care Home for Younger Adults 6 Category(ies) of LD Learning disability for 6 registration, with number LD(E) Learning dis - over 65 for 6 of places Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Not appliable Date of last inspection 15 Ocotber 2004 Unannounced 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. There are currently six male service users living at the home. 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 hand rail. 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. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day. The requirements and recommendations made as a result of the last unannounced inspection, dated 15th of October 2004 were discussed with the Registered Manager and their adequate implementation followed up. The inspector welcomed the opportunity to discuss a range of issues with the Area Manager for the home who was able to attend for most of the morning. One focus of these discussions and subsequently this inspection centred on behaviour management difficulties relating to one of the residents and experienced over recent months. The Commission has received a number of Regulation 37 notifications since the last inspection describing the extent of some of the incidents. The Registered Manager was present for the entire visit and helped to focus the inspection on the homes policies and procedures, care planning and organisational management and systems such as staffing, training and supervision. Samples of care plans/person centred plans were discussed. In addition care planning documentation including residents files were audited and policies and procedures for updating and maintaining these discussed with the manager. The visit included an extensive tour of the premises and equipment. Three members of staff were formally interviewed. Discussions with this group centred on their knowledge of formal assessments, person centred planning and day-to-day needs of residents. Interaction of staff with the residents who were present for some of the day was also observed. In spite of the considerable communication problems experienced by the residents at the home staff were able to facilitate meaningful and insightful contact between the inspector and the residents. The Commission received a number of ‘Comment Cards’ from relatives, residents and Health and Social Care professionals in contact with the care home prior to this announced visit. Views from these were incorporated into this report. One comment card was followed up in order to establish the exact nature of the comments made. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 6 Quality assurance information gathered during Regulation 26 visits carried out by the homes appointed visitors should form an essential part of the internal and external quality assurance process. The Commission received no Regulation 26 visit reports in 2005. Only two were received in 2004 after the last inspection in October of the same year. The very minimal information provided during these insufficiently frequent visits was also considered as part of this inspection. What the service does well: What has improved since the last inspection?
Residents can be more assured that only suitable staff are working at the home because the home is improving its information on staff. Some staffing information is now held at the home but closer inspection still revealed gaps. Current and future residents will benefit from a user friendly, transparent and informative Service User Guide. This has been completed since the time of the last inspection. Residents can be better assured that vital information about their needs is more comprehensively recorded in their plan of care. A requirement at the last inspection, Care Plans now better demonstrate how all service user’s individual identified/assessed needs are to be met. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 7 Residents and their families have better knowledge about statements of terms and conditions between the home and individual residents. All contracts are now signed by all parties and demonstrate that the terms and conditions have been agreed and explained to the individual service users. Residents can now feel better protected by Risk Assessments showing the full details of risk management strategies, resident’s involvement, their understanding of the risks and the person/s responsible for coordinating and reviewing agreed strategies. The right to complain to the Commission of all people connected to the home is now easier to execute because the home amended the Trust’s complaints policy to reflect that a complainant could refer a complaint direct to the CSCI. Residents can be more assured that only suitable staff are working at the home because the home is improving its information on staff. Some, but not yet all, staff employment records are held in the home and were available at the time of inspection. What they could do better:
Future residents would receive a better and more structured welcome and admissions unsuitable for the home could be avoided if an admissions policy was in place that guided and assisted staff in their understanding of admission processes and practices that should be followed. The current debate about the discharge of one particular resident would have been better informed and guided if a policy and guidelines on planned discharge and termination or self-discharge at short notice was in place. Resident’s individual freedoms and choice would be better protected if risk assessments were in place explaining restrictions relating to the use of a keypad system when opening the front door. The home’s duties and responsibilities under law would be better illustrated if the above practice of securing the front door was stated in its Statement of Purpose. Unnecessary risks to the health and safety of residents would be avoided if the home ensured that the secure cupboard in place for the Control of Substances Hazardous to Health was locked at all times. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 8 Internal quality assurance processes would lead to better outcomes for residents in a number of key areas outlined in Regulation 26 of the Care Home Regulations. These visits need to be monthly, a requirement, which the organisation is currently not even close in meeting. The implementation of an effective quality assurance and quality monitoring system would help the home to better assess whether it is currently achieving its aims and objectives to provide the best possible service for residents. The protection and personal safety of service users would be better demonstrated and supported if all staff employment records were kept in the home as required by Schedule 2 of the Care Homes Regulations. Residents and staff would benefit from clearer corporate guidance in key areas of policies and procedures if these were kept updated and held in the home and were as set out in Appendix 2 of the National Minimum Standards. Staff would be in a better position to ensure that resident’s are better protected if the home had in place an updated Protection of Vulnerable Adults Policy. Staff and resident’s health and safety would be better protected if the home kept to its own fire drill procedures and if residents’ not leaving the building when the alarm is sounded was risk assessed. 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 House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 9 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 House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5. Residents can be assured that Mulberry house can meet a wide range of complex needs in an open and transparent way. However, whilst there is a wide range of information available weaknesses were identified in procedural guidance regarding admissions. This was a major factor for the home to overestimate its ability to deal with the challenging behaviours of a resident and his other assessed needs. EVIDENCE: An updated copy of the Statement of Purpose was in place for inspection. The new Service User’s Guide has been discussed in the last inspection report but had not been fully completed at the time. This has recently been achieved and a copy has been sent to the Commission. The last report also recommended that policies and guidelines for admissions and discharges be put in place. The Registered Manager explained that all the policies and procedures required by regulation and set out in Appendix 2 of the National Minimum Standards are currently being updated and that the home had been informed that new folders containing these would be available on the 1st of July 2005. The manager agreed to send the new version so that this would be included in this inspection report. However, by the time this report had been completed no documents had been received (See also NMS 40). Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 11 One resident’s admission (2003) was case tracked and the complex circumstances of the admission discussed with the Registered Manager and the Area Manager. The home had expressed a reluctance to admit the resident at the time after initial assessments had revealed a high probability of the home being unable to meet some of the challenging behaviours of the new applicant. Assessed risks also included: Aggression to others, damage to self and damage to property and inappropriate approaches to children. A full psychiatric assessment was also available for inspection. In spite of these considerable risks and reservations and due to a number of circumstantial pressures the available place was nevertheless eventually filled. Subsequent developments proved these fears to be well founded a fact, which is well documented in the frequent Regulation 37 notifications of incidents (including a series of assaults), which have since been sent to the Commission. It is anticipated, that the new admissions procedures will be better in reflecting on the levels and boundaries of challenging behaviours the home is able to accommodate and the general suitability of a new placement after the trial period. The above mentioned resident is now planning to be discharged and staff expressed concern about the suitability of the housing scheme this resident is about to be admitted to. In the absence of a policy on the management of discharges the inspector noted that, similar to the homes early reservations and fears, the prospective new placement might also come under pressure from the complex needs of this resident. Requirements have been made in the relevant section of this report for both policies to be available within 1 month. Contracts outlining the terms and conditions applicable to the home and the residents were available for inspection on individual service users files. As required by the previous inspector, these agreements have now been signed. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9. Ongoing assessments is well reflected in individual Care Plans and Residents are encouraged to participate and are consulted on their choices. However, the home falls short to support its decision to restrict residents to leave the home by securing the front door on full and professional risk assessments. EVIDENCE: Ongoing assessment efforts were well reflected in individual Care Plans. Discussing some of this work with the registered manager good and relevant examples were given to demonstrate how the home delivers assessed needs on a day-to-day basis. The home wants all care plans to be informed by the Person Centred Planning method and is currently developing all plans according to that method. A number of Person centred planning folders were already available for inspection. Staff confirmed how they had been encouraged to ‘empower’ residents and be ‘inclusive’ and ‘participative’ when making decisions by the registered manager. A whole range of day-to-day issues was explored and staff complimented the home on how it endeavoured to include everyone in decision making on everyday and other equally essential issues.
Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 13 Standard 7 requires the home to risk assess limits to individual freedom thoroughly and record these in residents plan of care. The inspector noted that a keypad system prevented all of the residents from leaving the home by securing the front door. A full risk assessment should clearly state the reasons for this precaution and demonstrate why this practice is in the best interest of individuals and evidence its consistency with the purpose of the service. For this reason and to illustrate the home’s duties and responsibilities under law this practice should also be stated in the homes Statement of Purpose. By the time this report had been completed the home had complied with the requirement to provide a full risk assessment fully explaining the reasons for the restriction by sending a copy for inspection to the Commission. Standard 9 had previously been the subject of a requirement. Updated risk assessments had to be put in place for all service users, with their knowledge and cooperation. Risk assessments should show full details of risk management strategies, service user involvement, their understanding of the risks and the person/s responsible for coordinating and reviewing agreed strategies. This has not fully been achieved and risk assessments still need to be developed into more detail. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 14 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) 11, 12, 13, 14, 15, 17 The home enables residents to maintain appropriate and fulfilling lifestyles and residents are provided with good opportunities for developing emotional, communication and independent living proficiency. Nonetheless, ongoing arrangements for residents to attend supported work placements have had limited success. EVIDENCE: Throughout the inspection visit residents were observed engaged and busy, coming and going, with constant positive and lively interactions between residents and staff in evidence. In conversations with members of the team the inspector was able to gain a picture of the various strategies employed to involve all of the residents in regular and stimulating activities. Supervision records and team meeting notes confirmed that staff regularly examine approaches to ensure residents engage in a good and well rounded program of occupational, educational and therapeutic activities.
Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 15 Some of the residents attend Resource and Activity Centres during some part of the week. Ongoing arrangements for residents to attend supported work placements have had limited success. The home has a vehicle. This is used often for residents to enjoy the locality and trips out further from the home. Examination of activity plans showed that residents were encouraged to participate in a range of activities held in and outside the home. Integration into community life through meaningful leisure activities is given high priority. Residents are encouraged to participate in the day-to-day upkeep of the home’s environment and there was good evidence from conversations and observations that this includes tasks designed to enhance individual’s life and independence skills. Families were able to visit whenever they wished. Relatives/Visitors commented on this ‘open door’ policy very positively on feedback Comment Cards. There was good anecdotal evidence and sufficient recording to deduce that families and friends are welcomed and their involvement in daily routines and activities is encouraged. A balanced and nutritious diet was offered. Residents are involved in planning, preparing and serving meals. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 16 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. A flexible and efficient key worker system ensures consistent support for the residents. Healthcare needs are well assessed. Records relating to individual residents healthcare requirements are well maintained. Tools tracking health checks and screening services are in place. The administration of medicine is well managed. EVIDENCE: A key worker system provides each resident with sensitive, personal and flexible support. Time arrangements for routine events are kept flexible if residents require. The inspector was able to meet all residents during this inspection and outer appearance, their clothes and hairstyles was of a very good standard and always individual. There are a wide range of support services available for residents and the service makes extensive use of local healthcare facilities. The ‘OK Health Check’ pro-forma has been successfully implemented following a requirement from the last inspection. This tool tracks whether residents have been able to access general health checks or health screening services. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 17 Recording of medical and health input including medical and general health review sheets was seen to be of a very good standard. Arrangements to meet individual residents healthcare needs are good. None of the residents manage their own medication. All staff at the home are delegated to administer medication and have received relevant training. Policies outlining the homes storage, recording and administration of medication procedure are in place. The home uses colour coded blister packs to monitor individual dosages. Records kept were found to be without error. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 18 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’s complaints and POVA (Protection of Vulnerable Adults) procedures were found to be outdated (2000) and in need of updating. Staff’s understanding of protection issues is robust and sound as a consequence of frequent training offered by the Trust. EVIDENCE: The home recorded one complaint in the last 12 months. The records relating to this complaint were clear and well written and details of the investigation, action taken and the outcome clearly evidenced. Staff interviewed were clear about the organisation’s procedures and well informed about the role of CSCI in the complaints process. The home’s policies now include full details of the Commission after a requirement was made at the last inspection. Good evidence was provided that the Trust systematically trains its entire staff group on this topic. Members of the staff team at Mulberry House were last updated in September 2004 with one staff member taking part in the organisations ‘Vulnerable Adults Alerter’ training in February of this year. The home’s complaints and POVA (Protection of Vulnerable Adults) procedures were found to be outdated (2000) and in need of updating. This finding is also relevant for a number of other important policies and the staff team, as previously stated, expects the new and updated POVA policy to be available by the 1st of July 2005. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28. All of the six residents enjoy a clean, comfortable and safe home, showing a commitment from the staff team in maintaining the environment. Individual rooms are well maintained and personalised. Toilet and bathrooms are private and meet resident’s needs. EVIDENCE: The home accommodates six residents. Premises are suitable for the number of residents, safe, comfortable, bright and airy. All areas of the home were clean and free from unpleasant smells. Furnishings and fittings are of a good quality. Previous reports from the local fire office (May 2003) and Environmental Health Department (February 2004) were inspected. A requirement was made with regards to fire drill and evacuation procedures. This is outlined in more detail in NMS 42. The home has a planned maintenance and renewal program. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 20 The inspector was able to see three bedrooms that were found to be in line with NMS26.2. All rooms were personalised containing photographs, pictures and individual artwork. A number of toilet and bathroom facilities are located in close proximity to individual rooms. Staff are fully aware of privacy protocols. The home’s infection control equipment was inspected and found to be of a good standard. Infection control guidelines to inform staff are robust. Laundry facilities are appropriate. The secure cupboard in place for the Control of Substances Hazardous to Health was found open and the home is required to ensure that this unnecessary risk to the health and safety of residents is eliminated. The home makes satisfactory arrangements for the repair and maintenance of its stair lift. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 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) 31, 32, 33, 34, 35, 36. An experienced staff team is aware of and supports the home’s aims and values. Qualification and competency of the team is good with the group benefiting from ongoing training and development. Task focus and understanding of residents needs is impressive. The staff team is well supported through regular, good quality supervision. EVIDENCE: A core group of staff have worked for the home for many years and are very familiar, knowledgeable and supportive of the home’s aims and values. Staff understand how these values translate into policies and procedures and how to implement these in practise. The inspector was above all impressed with the team’s comprehensive understanding of the resident’s needs and circumstances. All those interviewed clearly maintained good and supportive relationships with the residents. This was also in evidence from observing staff interacting with residents. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 22 It was apparent through discussion with the manager that the home follows clear and robust recruitment procedures. The registered manager and interviews with staff confirmed that an offer of an appointment is only made subject to references, CRB, POVA, and medical checks. Staff documentation available for inspection at the home did not always include all the information required by Schedule 2 of the Care Homes Regulations. The manager is required to audit all staff files and send a copy of this to the Commission. Training and development records were inspected and found to contain documentation and accounts of relevant and regular training updates. Most staff are enrolled on a NVQ (National Vocational Qualification) 2/3 program. The quality of supervision records inspected was high and the home complied with the expected frequencies. The home employs 12 members of staff. Since the last inspection two staff have left and two new staff have been recruited. Rotas confirmed that a minimum of two members of staff are on shift at all times. More frequently three members of staff were recorded to be working together. One ‘Comment Card’ reported negatively about staffing levels at the home and claimed the home was overly reliant on bank staff. Scrutiny of rotas and discussions with the manager revealed this to be the case for brief periods only. These times were usually forced because of sickness of members of the core team. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 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) 37, 38, 39, 40, 41, 42. The manager of the home is about to complete the National Vocational Qualification Level 4 in Management. The home is currently not quality monitoring its own service nor is it auditing staff files satisfactorily. Policies and procedures urgently need updating and fire drill procedures need to be adhered to. EVIDENCE: The manager has just completed the last 2 units of the Registered Manager Award and is expecting to finish the NVQ (National Vocational Qualification) Level 4 in Management in September this year. Suitability Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 24 The inspector was left in no doubt that the home was well managed and that the registered Manager fully ensured that the responsibilities as outlined in NMS (National Minimum Standards) were fully adhered to. However four areas need attention in order for the home to comply with the relevant standards: • There was not enough evidence to assess whether the home was monitoring its own service as required by NMS 39. The inspector discussed quality assurance auditing with the Registered and the Area Managers. The Area Manager has considerable knowledge about the development of appropriate monitoring systems and reported about work recently done by herself and others on behalf of the Trust. She further reported, that a ‘Quality Assurance Audit’ paper was about to be published. The Commission has meanwhile received a copy of the scheme, which also includes a quality scoring system. However, the suitability of the quality assurance tool was not assessed during or after this inspection and future implementation will show its fitness for the intended purpose. The Registered Manager explained that all the policies and procedures required by regulation and set out in Appendix 2 of the National Minimum Standards are currently being updated and that the home had been informed that new folders containing these would be available on the 1st of July 2005. The Manager agreed to send the new version so that this would be included in this inspection report. However, by the time this report had been completed no documents had been received. Record keeping was of a generally good enough standard. This did not include the staffing information held at the home. Information held was not sufficient in order for the inspection process to be able to assess whether the home followed recruitment procedures that protect residents. The homes own fire drill procedure states that members of staff should participate in at least 2 drills per year. The way this was recorded did not allow for this to be assessed. In addition, logs showed that not all residents leave the building when the fire alarm is sounded. This fact needs to be risk assessed. • • • Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 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 3 3 3 x 3 Standard No 22 23
ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 2 2 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x 3 3 3 x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mulberry House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 1 1 1 2 x D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 26 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 1, 2, 9, 42 Regulation 4, 13 Requirement Risk assessments to be in place for each of the residents relating to the use of the key pad system securing the front door. The current restriction of securing the front door to be explained and outlined in the Statement of Purpose. The Registered Manager needs to ensure compliance with COSHH regulations at all times. Regulation 26 visits need to be conducted on a monthly basis. Put in place a quality assurance system. Staff employment records to be kept in the home as required by Schedule 4 of the Care Homes Regulations 2001. Policies and Procedures set out in Appendix 2 of the Regulations need to updated and kept in the home. The home needs to have an updated Protection of Vulnerable Adults Policy. The home needs to keep to its own fire drill procedures and risk assess residents not leaving building when alarm sounds. Timescale for action 1 month. 2. 1, 2, 9, 42 4, 13 1 month. 3. 4. 5. 6. 42 39 39 34, 41 13 26 24 17 Immediate 1 month. 1/01/06 1/12/05 7. 12 40 1/12/05 8. 9. 13, 41 9, 42 23 13, 23 1 month. 1month. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 27 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 2 2 Good Practice Recommendations An admissions policy to be put in place. A policy on the discharge of residents to be put in place. Mulberry House D56 D05 S3391 Mulberry House V226171 270605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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