Inspection on 29/01/06 for Mulberry House

This inspection was carried out on 29th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 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 28/07/06

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 Karen Walker Unannounced Inspection 29th January 2006 10:45 Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 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.V280376.R01.S.doc Version 5.1 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.V280376.R01.S.doc Version 5.1 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 Elva Verretta Bennett 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.V280376.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 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 five male residents 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 DS0000003391.V280376.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day on Sunday 29th January 2006. Information was gained for this report by speaking with staff and residents at the home and by examining care documentation. Other documentation relating to the general management of the home and health and safety was also examined. The requirements of the last inspection and standards not addressed at the last inspection were assessed on this occasion. What the service does well: What has improved since the last inspection? Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 6 This is the inspector’s first visit to this home however it was noted that some of the previous requirements have been met. 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.V280376.R01.S.doc Version 5.1 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.V280376.R01.S.doc Version 5.1 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): 4,5 Prospective residents have the opportunity to test drive the service. All residents have updated contract or terms and conditions of occupancy. EVIDENCE: The statement of purpose details the need for potential residents to ‘test drive’ the service. It details a gradual admission process beginning with a visit for tea followed by half a day. This then progresses to an overnight and weekend stay. One staff member confirmed that the home was unable to accept an emergency admission due to assessed needs not being met and the impact this may have on the other residents. There was also a detailed admission/discharge policy in place. Of the four-care planning folders examined none had a contract of terms and conditions of occupancy in place however following a telephone conversation with the manager on 6/02/06 it was confirmed that there were contracts in place that had been stored in a separate folder due to space constraints and were readily available for inspection. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Residents are aware of their assessed needs but will benefit from more detailed risk assessments to ensure the identified risks are reduced and managed. EVIDENCE: As required at the last inspection, the home must 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. The manager said a full risk assessment has been copied to the lead inspector for the home. This was not seen at this inspection. The statement of purpose was examined and had not been updated. Care plans and associated risk assessments were examined and discussions held with staff regarding service provision and individuals assessed needs. Essential lifestyle plans (ELP) have been developed with residents and contain positive information relating to the individuals hopes and fears and nonnegotiable goals. Good communication strategies were also in place to support residents and staff where verbal communication is limited. This is good practice. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 10 The quality of risk assessments varied from person to person and it was noted that some would benefit from a more regular review as the last recorded review date was in July 05. Some risk assessments must also be more detailed to ensure the staff are aware of how to reduce and manage assessed risks. One example of this was explained to a staff member and involved supporting a resident with cooking. Although the assessment identifies the risks it does not detail the support necessary to reduce the risk. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 11 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): 16 Residents’ rights and choices are recognised and respected. EVIDENCE: Staff confirmed that residents are encouraged to participate in the day-to-day upkeep of the home’s environment. There was also documentation in place relating to the choices individuals make. The service user guide highlights ‘residents rights’ and how they can expect these rights to be upheld whilst they live in the home. There was evidence that residents are supported to vote a staff member confirmed this. One resident was happy to allow the inspector to visit him in his room. Whilst it was noted by staff that it was his right to stay in his room staff were observed ‘checking on him’ periodically and ensuring that he was happy. Music and a TV were available to him. When asked if he was happy and comfortable in his room he replied ‘yes’ and smiled. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 12 It was reported that some of the residents had not had a holiday at all last year and it was questioned whether they would have one this year. The staff said that this was due to issues relating to staff pay. This must not affect the residents’ rights to an annual holiday and must be resolved. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 13 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): 19 Residents’ healthcare needs are assessed and met. EVIDENCE: There are wide ranges of support services available for residents and the service makes extensive use of local healthcare facilities. At the last inspection it was noted that the ‘OK Health Check’ pro-forma had been successfully implemented however through case tracking it was noted that one had not been completed. This tool tracks whether residents have been able to access general health checks or health screening services. There was written evidence to show that residents receive the appropriate healthcare support and the appropriate referrals are made. There is regular input from the psychiatrist and general practitioner. Staff members confirmed a good relationship with healthcare professionals and were impressed at how quickly one resident recovered from his hip operation with support from the general practitioner and district nurse. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 14 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): 23 Residents are not protected by a knowledgeable staff team in relation to protection issues. EVIDENCE: A discussion was held with staff members about the various policies in place to protect vulnerable people from abuse. This included the ‘No Secrets’ policy put in place by South Gloucester Social Services and the protection from abuse policy and Whistle blowing policy put in place by Aspects and Milestones Trust. One staff member was unable to explain any of the polices and did not know where to find them. The second staff member was unaware of the whistle blowing policy. Staff however were aware of the need to protect residents and described what was unacceptable behaviour from staff and others. All staff must read and sign the ‘protection’ policies and it is recommended that a record be kept of discussions held relating to staff understanding at supervision meetings and team days. Although one staff said he attended Awareness of Abuse training last year it is required that all staff attend a refresher. It is recommended that the training take place on an annual basis. At the last inspection it was found that the home’s complaints and POVA (Protection of Vulnerable Adults) procedures were outdated (2000) and in need of updating. The inspector could find no updated policy at this inspection. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 15 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): 24-30 The premises are suited to its stated purpose and are homely, clean and tidy. Bedrooms are individualised and residents have the equipment necessary to promote independence. EVIDENCE: 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 and are located in close proximity to individual rooms. Staff are fully aware of privacy protocols. The upstairs bathroom would benefit from a lick of paint around the windowsills where the paint is flaking off. There is a large well-maintained garden to the rear of the property and parking spaces at the front. The inspector was invited into three bedrooms that were found to be comfortable and homely. All rooms were personalised containing photographs, pictures and individual artwork. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 16 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 locked. The home makes satisfactory arrangements for the repair and maintenance of its stair lift. There is also a bath chair available in the upstairs bathroom and handrails appropriately sited to aid mobility and encourage independence. A staff member said and records confirm that the appropriate referrals are made to the occupational therapist to support residents whose mobility has deteriorated. Two residents have had hip replacements and both are fully recovered. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 17 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): 34 Residents are protected by robust recruitment policies but the records were unavailable for inspection at the home on this occasion. EVIDENCE: One staff member confirmed he had received a Criminal Record Bureau (CRB) check and said records relating to the recruitment of staff were held at head office. At the last inspection it was noted 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. In future the CSCI will make arrangements to view a selection of staffing records held at the Trust HQ to ensure safe practice. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 18 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): 39-43 Residents must be safeguarded from risk of harm and fire training must be carried out within appropriate timescales. Residents will benefit from resident meetings were recorded views and wishes can be translated into policy and inform service provision. Residents’ benefit from an accountable service. EVIDENCE: There were no minutes of resident meetings although one staff member said she had conducted a meeting last month but could not find the minutes. It is recommended that residents meetings be held on a regular basis and used as a platform to explore choices and preferences and to inform service provision. The in-house policy file was examined and it is recommended that this be indexed to enable ease of access. As previously reported in standard 23 some staff are unaware of the appropriate procedures to follow in the event of a protection issue. This must be addressed and policies and procedures made Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 19 readily accessible. Staff were unable to locate the Trusts policies and procedure folder. At the last inspection 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 the inspection report, no documents had been received. The requirement to ensure these policies are in place will be repeated. The fire logbook was examined and all of the appropriate fire checks were carried out within timescales dictated by the Avon Fire Brigade. The last recorded fire drill was in December 2005 but there was no evidence of up to date fire training. One staff member said this was carried in November 2005 at the team day. The manager is required to evidence fire training to the CSCI and provide an action plan for future fire training. The fire risk assessment was in place but the review sheet was left uncompleted. This requires attention. The fire policy was in place and had been adequately reviewed. Portable appliance testing (PAT) takes place on an annual basis and was last carried out in August 2005. The registered provider visits the home on a regular basis as per regulation 26. Meetings are held with staff and residents and documentation examined relating to the management of the home. This enables the provider to make an informed decision as to the standard of care provided at the home. The Commission receives reports. There is adequate insurance relating to the home and the certificate of registration remains valid. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 20 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 X 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 1 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 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X X X 3 2 3 2 3 Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation Schedule 1 Requirement Timescale for action 28/02/06 2 YA9 3 YA23 The current restriction of securing the front door to be explained and outlined in the Statement of Purpose. As last report timescale extended. 12(4)(a)(b)(c) Ensure all risk assessments 28/02/06 detail the action necessary to reduce the assessed risk. I.e. supporting a resident with cooking on a 1-1 basis. 18(1)(a)(c)(4) All staff must be aware of the 28/02/06 Protection policices and where to find them including whistle blowing, ‘NO Secrets’ and protecting vulnerable adults from abuse. All staff to attend the appropriate training. Dates to be forwarded to the CSCI. Evidence fire training to the CSCI and provide an action plan for future fire training for all staff. Policies and Procedures set out in Appendix 2 of the Regulations need to be updated and kept in the home. DS0000003391.V280376.R01.S.doc 4 YA42 18(1)(c) 23(4)(d) 17 28/02/06 5 YA40 28/02/06 Mulberry House Version 5.1 Page 22 As last report timescale extended. 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 3 Refer to Standard YA9 YA23 YA39 Good Practice Recommendations Review all risk assessments at least 3 monthly but prioritize those that involve behaviours that may challenge and review monthly with a detailed summery. All staff to read and sign the ‘protection’ policies and record discussions held relating to staff understanding at supervision meetings and team days. Residents meetings be held on a regular basis and used as a platform to explore choices and preferences and to inform service provision. Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Mulberry House DS0000003391.V280376.R01.S.doc Version 5.1 Page 24 - 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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