Inspection on 04/01/08 for Mulberry House

This inspection was carried out on 4th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mulberry House 07/07/08

Mulberry House 30/08/07

Mulberry House 01/06/06

Mulberry House 31/01/06

Mulberry House 21/06/05

Mulberry House 16/02/05

Mulberry House 22/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Mulberry House 120 Barton Road Luton Bedfordshire LU3 2BD Lead Inspector Mrs Louise Trainor Unannounced Inspection 4th January 2008 12:00 Mulberry House DS0000039287.V358436.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 DS0000039287.V358436.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 DS0000039287.V358436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mulberry House Address 120 Barton Road Luton Bedfordshire LU3 2BD 01582 570569 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) no email as at 5.7.7 Complete Care Services Limited Ms Wendy Snow Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2007 Brief Description of the Service: Mulberry House is located amongst a group of residential houses set back from the main road from Luton to Bedford in a residential area to the north of Luton. The home has access to local shops and public transport. The service was registered to provide residential care for eight people with learning disabilities. The service had been developed and operated by Complete Care Services Ltd for a number of years. The building has two storeys. The ground floor provides two bedrooms, a toilet, a large communal lounge/diner and a kitchen. Located on the upper floor is a staff area, a bathroom and six bedrooms. All of the bedrooms are for single occupancy and have en suite facilities. At the rear of the house is a garden with a small patio area. To the front of the property is a small garden. Copies of this report and others relating to this service can be provided on request. A copy of previous reports is available at the service. The fees for this home vary from £1200 per week, to £1600 per week, depending on the funding source and assessed need of the person. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a Care Home for Younger Adults that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the second Key Inspection for this service this year. Regulatory Inspector Mrs Louise Trainor carried it out on the 4th of January 2008, between the hours of 12:00 and 19:30 hours. The main focus if this inspection was to review the progress made and compliance with requirements left at the last Key Inspection in August 2007. The home Manager was not on the premises when we arrived for the inspection, as she had worked the previous night. However she was contacted by staff and returned to the home at 14:30 hours. She was then present throughout the remainder of the visit to assist with any required information. Verbal feedback was given periodically throughout and at the end of the visit. During the inspection the care of two people who use the service were case tracked. This involved, talking to them, visiting their individual bedroom areas with them, reading their records and comparing what was documented to the care that was being provided. Documentation relating to: staff recruitment, training and supervision and medication administration were also examined. The inspector spent some time talking with individual residents and staff. However a large part of this inspection was spent discussing, concerns with the manager, which were ongoing from the previous inspection in August 2007. The inspector would like to thank everyone involved for their support and assistance during this inspection. What the service does well: The system in place for staff to assess the needs of prospective residents is sufficient to ensure that they would have the information to know if they would be able to meet their needs. Care plans seen identified that people who live in this home have the opportunities to make decisions about their lives. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 6 People who live in this home have the opportunity for personal development through college and day centre attendance. This home provides a clean, comfortable and safe environment for the people who live in this home. What has improved since the last inspection? What they could do better: Support is given to encourage independence in the home, however there is a lack of risk assessment reviews to reflect how potential risks are managed. Record of receipt and disposal of medication is inconsistent so that reconciliation of stocks is not always possible. The review of care plans documentation is insufficient to ensure changing needs are met effectively and all people receive continuity of care. Leisure activities in the evenings and at weekends are limited for some people. The complaints procedure fails to identify a clear pathway for people to follow should they need to make a complaint, and senior staff in the home demonstrated that they are unsure of the correct procedure to follow in the event of safeguarding allegations being made. Recruitment systems in this home are insufficient to ensure that people living in this home are always protected. The manager failed to demonstrate a clear understanding of recruitment processes and Safeguarding issues which may compromise the protection of people who live in this home. The accident book was inspected. Since the 04/09/07 eight accidents had been recorded in this book, and five ‘violent incidents’ had been recorded. None of the five violent incidents had been reported via Safeguarding processes, and Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 7 only three of the accidents had been reported to CSCI through the Regulation 37 process. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system in place for staff to assess the needs of prospective residents is sufficient to ensure that they would have the information to know if they would be able to meet their needs. EVIDENCE: There were no new resident files to examine during this inspection, however as reported at the previous inspection on the 30/08/07. “Documents seen within the records of a person recently admitted to the home, showed several assessments of their needs. Representatives of the Primary care Trust, Social Services and staff of the service had completed the documents. Each representative had completed their own assessment documentation and further evidence was seen to show all had been involved in the decision for the person to move to the home. Documents described in detail the needs of the person; this included any diagnosis that had previously been made, the behaviours of the person and their individual aspirations alongside any risks. People that live in the home and entries within the daily notes confirmed that they had also had the opportunity to visit, prior to moving in. ” Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 10 Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans seen identified that people who live in this home have the opportunities to make decisions about their lives, however the review of care plans is insufficient to ensure changing needs are met effectively and all people receive continuity of care. EVIDENCE: The care plans for two people who live in this home were examined during this inspection. Information in these documents gave a clear picture of the individual’s needs, however they did not identify the specific level of assistance required to meet all their needs. One person’s file identified that their ability to manage their personal hygiene needs was affected by a short-term memory problem, but it did not explain what interventions were required by staff to ensure that these needs were met with continuity, or how this person preferred their care to be delivered. The plan identified that this person had a history of verbal and physical aggression, Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 12 and used de-stressing techniques to calm down, but it did not explain what actions were required from the staff to assist in this process. The risk of night seizures was also identified, but there was no clear guidance for observation or management of this, although one member of staff did inform us that they check this person every hour during the night, and a personal monitor is in place in the bedroom to alert staff if there is a problem. This persons’ care plan was dated May 07, and identified that it should be reviewed every three months. At the time of this inspection no reviews had been recorded despite a six month lapse since it was written. Risk assessments were in place to minimise potential risks for this person, however none of these had been reviewed for over a year. This person keeps their own medication in their room and is supported by staff, however there was no care plan or risk assessment to reflect this. Resident’s meetings are held once a month, and the people who live here are encouraged to give their opinions and contribute to making decisions about different aspects of life in this home. However comments from residents included. “You can’t choose the food, you just have to have what everyone else has”. “I’d really like to go out shopping more often”. And “All we ever do is watch videos at the weekend”. These comments indicated that perhaps individual’s wishes and preferences are not always considered when choices and decision are made, particularly in relation to leisure time and meals. However the provider has responded to these comments. He stated that although they do sometimes have ‘video evenings’ with lemonade and popcorn, the residents are invited to participate in a variety of other activities such as crafts and games. These invitations are often declined at the time, and then boredom is complained about later. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in this home have the opportunity for personal development through college and day centre attendance, however leisure activities in the evenings and at weekends are limited for some people. EVIDENCE: There are presently seven people living in this home. With the exception of one person, all attend a day centre or the local college, one, two or three days a week. One person explained how she is learning photography at college and another brought home some tarts she had made in a cookery lesson at college. This was very positive and demonstrated how much they enjoy their personal development. They also have a ‘music man’ who comes to the home once a fortnight, and they are encouraged to sing and play instruments. Unfortunately though, they explained that they do not attend evening clubs or groups any more. One person told us, that this is due to the fact that a member of staff has the minibus at weekends, as she has had no personal Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 14 transport since August. The Provider explained, that this member of staff only had the minibus when there was no driver on duty, so that if there was ever an emergency she could be called on, as she lives very locally to the home, to come in and provide transport if required. Boredom was reflected in the comments received from some residents. One said. “All we do at the weekends is watch videos”. Another said. “We don’t go to evening clubs anymore, we just stay at home.” This matter was also discussed with the Provider, who informed us that, Mulberry House lost its’ membership for one club, due to infrequent attendance where the residents regularly refused to attend. They have also recently stopped attending another evening club that was held further a field, because the journey through the ‘rush hour’ traffic was causing some residents to get very stressed. There is however another more local venue that holds ‘disco s’ that some residents have recently started attending. The people, who live in this home, each have a ‘House Day’. Two residents explained that this is when they do their chores in the home such as, cleaning their rooms, doing their laundry and assisting with kitchen duties. However one person told us, that the washing machine keeps breaking down which results in the home having to rely on trips to the launderette, which are very expensive. The home manager, who said that they have to wait for the homeowner to return from holiday to purchase a new machine, confirmed this. Contact with families is encouraged, and two of the residents talked about the time they spend with their families. One said. “My family are in London and I do go and stay with them from time to time”. Another talked fondly about how she spends her birthdays with her 87-year-old mother, who also tries to visits her once a month. Menus for this home were inspected. Although they identified a variety of meals, there did not appear to be much choice, and if someone did not like the main meal of the day, there were limited choices available as alternatives for them. These only included quick convenience foods, such as frozen pies or fish fingers. As the residents are not asked in advance of the meal preparation, if they like the meal on the menu, there is insufficient time to safely defrost something such, as a chicken breast that would provide a more substantial alternative. Residents do not appear to have been involved in the planning of the menus. One said, “If you don’t like something on your plate, they just say leave it, but we don’t always get given something else”. On the day of the inspection, the evening meal was corned beef hash and fresh vegetables; one person did not like this meal and had toast as an alternative. We appreciate that this was what the resident said she wanted, however it was the main meal of the day, and there seemed to be limited alternatives available or encouraged. We were advised by the Provider that new menus are in the process of being devised with input from the people who live here. The fridge content was inspected. It contained several packets of opened cooked meat. These had either; not been resealed, and had dried up and Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 15 curled at the edges, or were out of date. There was a packet of pitta bread that was opened and dried up and numerous jars that had not been dated on opening, including a tub of mince meat, which read. “Use within four weeks of opening”. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 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. 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 this service. Support is given to encourage independence in the home, however there is a lack of risk assessments to reflect how potential risks are managed. Record of receipt and disposal of medication is inconsistent so that reconciliation of stocks is not always possible. EVIDENCE: It was encouraging to see that one person in the home is on a self- medicating regime. Her medication is kept locked in a safe in her bedroom, and she talked confidently about why and when she requires it. Unfortunately the manager was unable to locate a risk assessment to reflect this care practice. Two individuals indicated that they would like to hold the key for their rooms. There did not appear to be risk assessments relating to this in the individuals files, and the individuals thought it would not be allowed. Comments from people who live in this home reflected that they felt generally well cared for and well supported. Observations of staff / residents interactions Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 17 indicated a relaxed atmosphere of companionship with a mutual respect. The residents all appeared content whilst going about their daily routines whether independently or with support from the staff team. One person said. “I like all the staff here they’ re very loving and caring, much better than where I was before”. Numerous care plans and risk assessments were in place for the two individuals that we ‘case tracked’ during this inspection. Some of these were very detailed and gave clear instructions relating to the level of assistance required. They included personal preferences and aspirations; behavioural management plans, and preferred personal de stressing techniques. Unfortunately many of these had not been reviewed and updated, and therefore did not accurately reflect the present level of care required. One person’s risk assessments showed no evidence to suggest that it had been reviewed since September 2006, despite a three monthly review date being specified. The medication systems in the home were inspected. Medication is generally dispensed in individual cassettes and these are appropriately stored in a locked facility. There was a Homely Remedy Policy present in the file containing the Medication Administration Record (MAR) sheets. The list of sample signatures was out of date, as was the list of staff that are trained and permitted to dispense medication. Each individual had a photograph and a personal profile sheet containing detail of allergies, GP and other relevant information. Two members of staff had signed each medication that had been administered and omission codes had been recorded where necessary. The only concern relating to medication was the reconciliation of the medication that is not dispensed in the cassettes. It was not being clearly recorded when it was carried forward or returned to the pharmacy. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaints procedure fails to identify a clear pathway for people to follow should they need to make a complaint, and senior staff in the home demonstrated that they are unsure of the correct procedure to follow in the event of safeguarding allegations being made. EVIDENCE: There is no complaints procedure on display in this home. Although there are sheets in picture format, which are given to all residents to identify with, which are faces with different expressions that ask questions such as; “Why am I sad?” “What will make me happy?” and “How long will it take?”, this does not tell people how to raise concerns, and they are not on display and readily accessible for everyone at all times. The written policy is very generalised and does not specify a timeframe for a written response to be received, so people would not know what to expect if they did make a complaint. At present it is not produced in a format that would be understood by everyone who lives in the home. This home manages personal allowance expenditure for six of the seven people who live in this home. The account files of two residents were inspected. Records were clear; all transactions were appropriately signed, and balanced correctly with funds remaining. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 19 At the last inspection in August 2007, an immediate requirement was left relating to Safeguarding procedures in this home. During this inspection the manager was unable to locate the reviewed Safeguarding Protocols and Policy, which she said she had recently obtained from the County Council. The policy that she had was dated 2004, and stated, ‘A full investigation involving the alleged parties, needs to be documented and statements taken and signed’. This policy is out of date and misleading. There was no clear policy or procedure, for staff to follow if they needed to report safeguarding issues. When given a scenario of alleged abuse, both the manager and her deputy said that they would interview staff and investigate the incident. This matter was discussed at length with the manager and the inspector stressed that no investigation should be commenced within the home, until the Safeguarding Team have met and agreed a course of action, as this could impede any criminal investigation that may be necessary. It caused concern that the manager has done ‘in house’ training on this subject with all her staff. Therefore it is likely that their understanding of these procedures is also incorrect. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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 this service. This home provides a clean, comfortable and safe environment for the people who live in this home. EVIDENCE: A full tour of the premises took place during this inspection. The home was free from any offensive odours. Communal areas were spacious and comfortable, all the individual’s rooms had en suite facilities and were furnished and decorated according to personal taste, and all had en suite facilities. One person’s room was decorated and accessorized in ‘Playboy’ pink, which was this person’s favourite colour. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 21 Another person had a wicker chair that she had purchased herself form a local garden centre. Both of these rooms were furnished with pictures and personal belongings that reflected their hobbies and personalities. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment systems in this home are insufficient to ensure that people living in this home are always protected. EVIDENCE: The files of three staff working in this home were inspected. , however two of the files inspected did not contain the required Home Office documentation for these individuals. One file contained a letter from a solicitor dated 2005, stating that this individual had permission to work in the UK, and another had a student visa, but lacked the accompanying documentation for work purposes. The main concern for us was that the manager had not followed up on this information, and had felt it acceptable for these people to commence work without confirming the authenticity of their documents. An Immediate requirement was issued regarding this matter. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 23 Personal training records identified that not all staff are attending mandatory training as required. Two individual’s files contained certificates achieved prior to coming to work in this home. These were for mandatory subjects that should be refreshed annually. Many of these expired in March 2007. This is not acceptable. Staff that were interviewed were confident in their roles, and were able to demonstrate through interviews and discussions their competencies and understanding of the needs of the people they care for. Relationships between staff and the residents in this home were friendly, respectful and supportive. One member of staff informed us that there is a staff meeting held during the first week of each month, which gives everyone the opportunity to voice their opinions. Records indicated that staff are being supervised on a regular basis by a senior member of staff. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager failed to demonstrate a clear understanding of recruitment processes and Safeguarding issues which may compromise the protection of people who live in this home. EVIDENCE: As detailed elsewhere in this report, the manager had failed to authenticate crucial recruitment documentation, when appointing staff to this home. During this inspection the manager demonstrated through discussion, that her understanding of the safeguarding procedure was that she should investigate allegations. She was unable to locate the up to date local protocols, and the 2004 document that she had on file was very misleading. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 25 The accident book was inspected. Since the 04/09/07 eight accidents had been recorded in this book, and five ‘violent incidents’ had been recorded. None of the five violent incidents had been reported via Safeguarding processes, and only three of the accidents had been reported to CSCI through the Regulation 37 process. Some of the key policies in the home, including Complaints, Recruitment, Safeguarding and reporting, are either out of date or not being appropriately followed. Each resident has risk assessment s in place. However there is little evidence that these are being reviewed to reflect changes. One file inspected contained numerous risk assessments including one for seizures, crossing the road and self-harming behaviour. None of these had been reviewed for over a year. This person did not have a risk assessment for self-medicating, despite the fact that they keep some of their medication in their room and administer it themselves. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 32 2 33 2 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 1 2 1 X Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement A plan of care must be in place to ensure all risks, measures and guidance is clear to staff to protect people living at the home and staff from harm. These must be appropriately reviewed to reflect changes in need. Requirement partially met 31/08/07 – new timescale applied People who live in this home must be included in the decision making relating to the care they receive. And the day-to-day running of this home. People who live in this home must be protected by risk assessments that are regularly reviewed to reflect the changing levels of assistance required to minimise potential risks. The complaints procedure must be revised so that it contains accurate information for the people who live in this home to follow, should they need to complain. Previous timescale 30/09/07 DS0000039287.V358436.R01.S.doc Timescale for action 31/03/08 2. YA8 12(2) 31/03/08 3. YA9 13(4)(b) 31/03/08 4. YA22 22(7) 31/03/08 Mulberry House Version 5.2 Page 28 unmet 5. YA23 13(6) People who live in this home must be protected by staff that can demonstrate that their knowledge of local policies and reporting procedures relating to Safeguarding, is accurate and up to date. All documents specified in paragraphs 1-7 of schedule 2, must be obtained for each employee, prior to commencing employment, in order to protect the people who live in this home. This must include Home Office documentation for all overseas staff. Immediate requirement left. The views of people at the home and their representatives must be sought and then acted upon so that they have the opportunity to influence the running of the home. Previous timescale unmet 31/10/07 Policies relating to recruitment, complaints, safeguarding and accident reporting must be reviewed so that the people in this home are protected. Any accident or incidents, which adversely affect the people living in this home, must be reported to CSCI and any other appropriate authorities. Immediate requirement left 31/03/08 6. YA34 19(1)(b) 07/01/07 7. YA39 24(3) 31/03/08 8. YA40 22 13(6) 19(1)(b) 37(1) 37(1) 31/03/08 9. YA42 07/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000039287.V358436.R01.S.doc Version 5.2 Page 29 Mulberry House 1. YA24 Consideration should be given to the suitability of the style of furniture that is being used as the dining table and chairs. Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mulberry House DS0000039287.V358436.R01.S.doc Version 5.2 Page 31 - 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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