Inspection on 28/07/06 for Mulberry House

This inspection was carried out on 28th July 2006.

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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mulberry House 21/01/08

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 Key Unannounced Inspection 28th July 2006 09:30 Mulberry House DS0000003391.V304538.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 Mulberry House DS0000003391.V304538.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. Mulberry House DS0000003391.V304538.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 To be appointed Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 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. 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 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. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The purpose of the site visit was to review the progress to the requirements and recommendations made at the last visit in January 2006 and review the quality of the care provided for the residents living at Mulberry House. The focus of the site visit was on the general care of a sample group of residents and the environment, including an extensive tour of the premises. This provided a good opportunity to observe residents as well as allowing for informal conversations with individuals and the staff supporting them. Three members of staff were spoken with during the inspection, which included the senior carer. The home has been sending information in respect of regulation 37 notices of events affecting the well being of the residents and these were used as a focus for the site visit along with the pre-inspection questionnaire completed by the home, relatives (2), professional (2) and residents (5). The site visit was conducted over a period of 7 hours. What the service does well: What has improved since the last inspection? Residents are protected by risk assessments in a variety of activities both in the home and the community and these have been kept under review and updated as needs change. Residents are protected by clear documentation on the current restriction of closing the door detailing the decision process. Residents and staff benefit from having policies and procedures to guide and support them. These have been reviewed and updated. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 6 Residents now benefit from having regular meetings to enable them to explore choices and preferences, which inform service provision. Staff have increased their awareness on issues of protection and policies to ensure that residents are safeguarded in the event of an allegation of abuse. 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. Mulberry House DS0000003391.V304538.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 Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. 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 the service. Residents can be confident that there is sufficient information available to them to make an informed decision on whether to move to the home. EVIDENCE: The home has a statement of purpose and a service user guide in place, which meets with the legislation. This requires amendment to include the recent change in manager. The service user guide was available in plain English and pictorial format to enable the information to be more accessible to the residents. The statement of purpose clearly describes the assessment process and the need for potential residents to “test drive” the home. The home has an established group of residents. The last person to move to the home was in 2000. The home presently has one resident vacancy. There was a clear criteria that the home can use for admission of a prospective resident in the statement of purpose. The process was clearly described in the Trust’s policies and procedures manual. Staff described how the home was managing the resettlement of an existing resident in to a potential new placement, which included supporting them in Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 9 visiting their prospective new home. Records of the visits were being maintained. All residents have updated contract or terms and conditions of occupancy, as seen at the last site visit. Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s benefit from a person centred approach to the planning of care. However, there was a lack of a formal review of the individual’s goals. Residents are protected by the home’s risk assessments. Residents can be confident that information about them is treated with confidence. EVIDENCE: Essential lifestyle plans had been developed with residents and contain positive information relating to the individuals hopes and fears and non-negotiable goals. An external facilitator in person centred planning is assisting the home in developing clearer plans of care. Much of the care documentation seen was not dated or signed and made it difficult to determine how current the documentation was. The National Minimum Care Standard clearly states that all plans should be reviewed a minimum of six monthly or more frequent depending on the needs of the residents. Care plans seen have not been reviewed since July 2005 in relation to two of the residents. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 11 Since the last inspection the home has reviewed and updated all the individuals risk assessments. It was pleasing to see that where residents needs have changed that these have been amended or a new risk assessment implemented. Risk assessments provided clearer guidance to staff on the support required by each individual in response to comments from the last site visit. Resident’s care plans included information on how residents are supported to make decisions and guidance on how each individual communicates in the form of a communication dictionary. Concerns were raised at the last inspection that there was no documentation supporting the use of the key code pad system to the front door. This is now in place and links with the assessed risks for the individuals living in the home, ensuring their safety from the main road. Evidence was provided that residents have a forum to explore choices and preferences and to inform service provision in the form of regular monthly meetings. From talking with staff it was evident that where requests were being made this was put into place. For example two of the residents wanted to go on a train ride. The senior carer stated that this was being planned for August 2006. This is good practice and evidently empowering for the individuals living in the home. Information was held securely and conversations of a confidential nature were conducted in the office with the door shut. A resident very clearly indicated to the inspector which of the files was their care file and was keen for this to be looked at including the photograph on the front. Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. 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 the service. Residents have good access to the community and take part in meaningful activities. Residents have good contact with friends and families. Resident’s rights are respected and actively encouraged to participate in the running of the home. Residents have access to a varied menu, which is based on preferences. EVIDENCE: Residents are supported to actively access the community with staff support. Care files and daily diaries included how the person liked to spend their time both in the home and the community. Each individual had a structured care plan including access to external day care. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 13 Fortnightly trips were organised to a local hydro pool and in between attendance at the local swimming baths for some of the residents who benefit from this form of relaxation and exercise. Other activities included attendance at a local social club for individuals with a learning disability and attendance at a bingo session. One resident made gestures that they attend a keep fit class and it was evident that they found this to be enjoyable. It was noted at the last site visit that none of the residents benefited from an annual holiday last year. This has been rectified and holidays have been planned for the individuals living in the home including day trips throughout the summer. One resident prefers to spend time in their bedroom away from the noise levels downstairs. It was noted by staff that it was his right to stay in his room if he chose, staff were seen regularly checking on him periodically and ensuring he was happy. Music and a television were available to him. The resident indicated that he was happy living at Mulberry House, and was keen to show the inspector his bedroom. The home has access to an 8 seater mini bus, which has been specially adapted to suit the individuals living in the home. The individuals via their Disability Living Allowance fund this; in addition contributions are made for petrol based on usage. A member of staff said that the deduction for the vehicle is completed by the Finance Department. Documentation was not seen on this occasion supporting the decision process or to ensure that this was equitable. This will be followed up at the next inspection. The service user guide highlighted “resident’s rights” and how they can expect these rights to be upheld whilst they live in the home. Further evidence that the residents were involved and consulted in the running of the home was via the residents’ meetings. These focused on menu planning and activities and whether residents were happy. Residents were supported to go out for a walk and lunch on the day of the inspection. The inspector was invited along to participate in the lunch along with the senor carer. The atmosphere was relaxed, residents were supported sensitively and it was evident that staff had a good knowledge of the needs of the residents. It was evident that the residents enjoyed their outing. Menus were submitted prior to the inspection visit and demonstrated that residents had access to a nutritious and balanced diet based on the preferences of the residents. Fresh fruit was plentiful and residents could help themselves. Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s personal and health care needs are being met. This will be enhanced if relationships were built with the local community learning disability team to ensure a consistent approach based on advice from the professionals, which informs the care provision. Residents are protected by a robust system of medication administration. EVIDENCE: Care plans evidenced that individual’s personal and health care needs were being met. Residents attend appointments with doctors, dentists and opticians and where relevant chiropodists. Feedback from professionals was less than positive in that “nightmare getting any recommendation applied especially with an element of common sense” and “one appointment there was only relief staff and no one aware of the appointment”. Another professional echoed similarly “with the staff want professionals to make problems better without any input from the staff”. Both saw the prospect of a new manager as a positive way of dealing with the change. Discussions with the senior member of staff on duty at the time of the inspection highlighted that there were some difficulties with one resident who Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 15 has since moved. It would be recommended that the new manager speak with the local community learning disability team to address these concerns. Residents were being supported in a positive manner and personal care was completed sensitively and in the privacy of their own bedroom or the bathroom. It was evident that residents chose when to get up and go to bed. This was evidenced via care documentation. On the day of the inspection one of the residents did not wake up until mid-morning and from discussions with staff this choice was respected. Staff confirmed that the day is planned around the care needs of the residents, it was highlighted that much of the morning is taken up with personal care with activities planned from late morning onwards. Medication was stored, recorded and administered appropriately. All staff had either attended training with the local chemist or this was planned in the case of the newest member of staff. Policies and procedures were in place to guide staff. Staff training was planned based on the care needs of the residents, some staff had attended training in supporting residents as their get older, dementia care and autism. Less apparent was supporting individuals that challenge. However, the senior carer was able to demonstrate that this was being organised for the whole team. Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. 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 the service. Residents can be confident that they concerns are listened to and that they are protected by the home’s procedures on protection. EVIDENCE: A complaint and protection procedure was in place as seen at the last inspection. The pre-inspection questionnaire indicated that this had recently been reviewed. The complaint procedure was in an accessible format. Care records included information on how residents communicate including when they were unhappy. Staff described how they were supporting individuals that did verbally communicate. Training records included evidence that staff were attending periodic updates in makaton to improve methods of communication for individuals that are non-verbal. Staff have had discussions in team meetings in relation to the reporting of abuse and further training is planned for one individual. This was in response to a requirement of the last site visit and the home has demonstrated compliance. The majority of staff attended a course on protection in 2004. In addition new staff complete an alerter course to abuse as part of their induction. The home has clear financial policies and procedures to ensure that the residents and the home’s budget are protected. Finances were being checked at regular intervals by the care staff. The manager is the appointee for all the residents. All residents have their own bank accounts. Financial audits are Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 17 completed at regular intervals by the Trust’s Financial Department. Two signatures support all expenditure and two named staff are required to make a withdrawal from a resident’s account. These safeguards are seen as good practice in protecting residents’ finances. Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have available to them a homely and clean environment which meets their assessed care needs. This would be enhanced with the carpets being replaced in communal areas and one bedroom on the first floor. EVIDENCE: The premises comprise a detached house on two floors with six single bedrooms. There is one bedroom on the ground floor. Bathroom and toilet facilities are situated on both floors and are located in close proximity to individual’s bedrooms. The home is in keeping with the local neighbourhood. There is a large wellmaintained garden to the rear of the property and parking spaces to the front. Access to the building is via a keypad system. Documentation was in place supporting its use with clear guidelines for bank staff. This was in response to a requirement from the last inspection. Resident’s bedrooms were personalised and comfortably furnished. There was heavy staining on carpets in one bedroom on the first floor and in communal Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 19 areas. The senior carer stated that carpets are in the process of being replaced in communal areas including the office however this did not include the upstairs bedroom. It was noted that the resident prefers to spend their time in their bedroom and the carpet must either be deep cleaned or replaced. The home makes satisfactory arrangements for the repair and maintenance of the premises. It was evident that due to the resident’s behaviours that items are routinely replaced if broken. It was noted that the toilet roll dispenser on the ground floor requires replacing. This was entered in to the home’s repair book on the day of the site visit. The home has aids and adaptations to meet the care needs of the residents, including a walk-in shower, handrails and a bath chair. The home has a stair lift, which a member of staff stated was broken and the new manager has identified that this should be removed as no resident has an identifiable need to use the stair lift at this moment in time. There were good systems for infection control as seen at the last inspection. Sluice facilities and separate laundry facilities were sited away from the kitchen. Staff confirmed that laundry facilities whilst constantly in use were adequate for the size of the home and the needs of the residents. All parts of the home were clean and homely. Care staff complete the cleaning chores as part of their day-to-day role. Cleaning schedules were not seen on this occasion. Staff stated that residents will assist but generally the care staff leads this. Mulberry House DS0000003391.V304538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported by sufficient staff. There is a good training programme and support mechanisms for staff. EVIDENCE: The duty rota provided sufficient evidence that the home was staffed adequately to meet the assessed care needs of the residents. There was always two staff on duty during the day with one member of staff providing waking night cover. In addition a third person was employed to enable residents to access the community. Staff stated that in the morning it is beneficial that there is a third member of staff so that personal care needs of each of the residents can be met. It was noted that if there was not a third member of staff at the beginning of the shift a member of staff usually started at 10 am. Recruitment information was available for staff in all cases other than the most recently appointed person. It was evident that the home was requesting this information from the head office. There were good recruitment procedures in place to ensure the safety and protection of the residents from initial advert through to interview and ensuring all documentation is in place prior to commencing in post. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 21 It was evident from records and conversations with staff that there were good support mechanisms in place including regular staff meetings, supervisions and annual appraisals. Staff training was in place and covered a wide range of topics relevant to the care of the individual residents. There was a good rolling programme of health and safety training for all staff. Staff spoken with during this inspection stated that the home is running well and there is a good team spirit in the home and the new manager is enhancing this. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is under new management; however there were good systems in place and staff saw the management change as positive. Morale in the home was good and staff spoke positively about support mechanisms Resident’s health and safety is being compromised through lack of staff fire training and attendance at fire drills. EVIDENCE: A new manager Mrs Webb has started working in the home as a temporary measure between managers. The Trust has written to the Commission for Social Care Inspection stating that this process could take up to six months. It has been required that the temporary manager registers with the Commission in view of the long time scale. Confirmation was received from Mrs Webb that this process has commenced. Staff spoke positively about the management change and that morale in the home was positive. There was evidence that there were regular team building Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 23 days at least every two to three months. Staff confirmed that a variety of topics are discussed including supporting the individuals, talks from professionals, makaton training and general issues relating to the running of a care home. This is good practice. Staff confirmed that this would continue with the new manager. Resident’s monthly meetings minutes were seen. The home has responded to a recommendation from the last inspection to ensure that these are held regularly. Policies and procedures were not viewed on this occasion. However, evidence was provided via the pre-inspection questionnaire that these are in the process of being reviewed and updated. Staff have signed core policies and procedures. A file had been organised for bank/relief staff, which included significant policies and procedures, information about the home and the residents and contact details in the event of an emergency. The fire logbook was examined. Whilst there were checks being completed on the equipment in accordance with the fire brigade’s recommendations, least apparent was fire drills and periodic training. Three staff had not attended a drill in the last six months and it was only evident that staff had attended annual fire training. Staff must attend a fire drill once in a six-month period and receive training three monthly for night staff and six monthly for day staff. Fire training remains an outstanding requirement from the last inspection. Further non-compliance could lead to enforcement action being taken. An immediate requirement was left with the home for these to be addressed within seven days. There were good systems for ensuring the safety of residents including window restrictors on all first floor windows, water temperatures being maintained to a safe temperature and regular audits completed on the premises. In addition electrical testing was completed and an annual gas certificate received. There was a good rolling programme of ongoing health and safety training, with clear records being maintained of attendance and courses planned for the future. The registered provider visits the home on a monthly basis as per regulation 26 and reports of these are being sent to the Commission for Social Care Inspection. Audits were being completed on the environment and residents were consulted about their care during the monthly meetings. In addition residents views were sought at care reviews. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 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 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X X 3 3 3 3 2 3 Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 25 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. 2. 3. Standard YA6 YA26 YA42 Regulation 15 (1) 23 (2) (d) 18(1)(c) 23(4)(d) Requirement Timescale for action 28/10/06 4. YA42 23 (4) (e) To ensure that all care plans are reviewed at least six monthly. Replace or clean carpets in all 28/10/06 communal areas and bedroom on first floor. Evidence fire training to the CSCI 05/08/06 and provide an action plan for future fire training for all staff. In accordance with fire brigade’s recommendations three monthly for night staff and six monthly for day staff. (Outstanding since 28/02/06) All staff to attend a fire drill once 05/08/06 in a six-month period. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations For the manager/care staff to foster professional relationships with the local community learning disability team and ensure advise followed. Meeting to be arranged to discuss past history. DS0000003391.V304538.R01.S.doc Version 5.2 Page 26 Mulberry House 2. YA6 Ensure care documentation dated and signed, where possible include resident signature. Mulberry House DS0000003391.V304538.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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