Inspection on 20/12/05 for Mullion

This inspection was carried out on 20th December 2005.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mullion 05/12/08

Mullion 06/12/06

Mullion 06/07/05

Mullion 25/01/05

Mullion 20/09/04

Mullion 15/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Mullion 230 Portsmouth Road Horndean Hampshire PO8 9SY Lead Inspector Tracey Box Unannounced Inspection 20th December 2005 09:30 Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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 Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mullion Address 230 Portsmouth Road Horndean Hampshire PO8 9SY 023 9259 6820 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) www.c-i-c.co.uk. Community Integrated Care Mr Stephen Richard Brockway Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD may only to be admitted between the ages of 30 and 45 years 6th July 2005 Date of last inspection Brief Description of the Service: Mullion is a registered care home, providing personal support and accommodation for three young adults with learning disabilities. Mullion is a bungalow set back from the main road just outside Horndean. Mullion bungalow is owned by Knighstone housing association. Stephen Brockway is Mullion`s registered manager, Community Integrated Care are the service providers. Mullion comprises of three single bedrooms, a communal lounge, dining room and kitchen, a laundry and an enclosed garden. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The two people living at Mullion prefer to be referred to as Service users, therefore will be referred to throughout the report. The inspector witnessed good interacting between two service users and staff who were participating in activities that service users seemed to enjoy, which included watching television and spending one to one time with staff sitting close by. The inspector looked at records which were available, and asked staff for their views and opinions of working in the home. The home appeared clean and comfortable, providing a pleasant environment for the service users. The home will be issued with a new registration certificate as the following condition is not needed and can therefore be removed: 1. Service users in the category LD may only be admitted between the ages of 30 and 45 years. What the service does well: What has improved since the last inspection? A permanent fence panel has been placed at the back, left hand side of the garden. The home has a full complement of staff, Staff morale is high resulting in an enthusiastic workforce that works positively with service users . Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 6 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. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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 Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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): 2 The home has a clear procedure for assessing the needs and aspirations of potential new service users to ensure the service users and the homes needs are met prior to admission. EVIDENCE: The inspector sampled the homes admission policy and procedure which clearly states the process of assessing prior to admission, and that a placement is only agreed once the potential service user has received written confirmation of their placement by the home. No service user has been admitted to the home since it was registered in July 2002. Service user’s files did not show records of pre placement assessments taking place prior to service users admission to the home. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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): 6,7 (standard 9 was assessed during the previous inspection.) Service users’ individual plans reflect their assessed and changing needs and personal goals. The systems for service user consultation are good with a variety of evidence that indicates that service users views are both sought and acted upon, which enables service users to make decisions. EVIDENCE: The inspector read both service user’s care plans which included comprehensive risk assessments on all areas from personal care needs, to travelling in a vehicle, going on holiday, attending activities, fire evacuation (during day and night) and daily activities. The inspector spoke with the staff, who confirmed the way they ensure service users views are listened to is to communicate in the style and pace appropriate to the individual, spend one to one time with service users, arrange regular review meetings, form positive relationships with families, friends and outside agencies. One member of staff confirmed staff use a variety of ways to enable service users to make choices, for example, when choosing which clothes to wear, the staff member will arranging the options in front of the service user and prompt the service user to look and point to their choice. The same system is used Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 10 when choosing to redecorate/ refurbish of areas within the home and where to go on holiday. One member of staff said the care plans are reviewed almost daily, any changes are discussed with the service user and agreed before any action is taken, signed documentation showed this practice occurred. Care plans and risk assessments are also reviewed at the service users annual essential life plan (ELP) review, where relatives/representatives, day placement representative and social workers are invited if the service user wishes, the inspector saw two service users files which included names of people who attended. Each service user has a timetable of daily activities, which is devised and agreed with them at their review. The home operates a keyworker system, which means each service user has a named member of staff who has specific responsibilities for the service user. A member of staff said “ I often spend one to one time with the service user I am keyworker to, we may spend time doing an activity, this promotes a relaxed atmosphere so that the service user feels able to communicate their wishes and we get to know one another.” The inspector saw staff communicate with service users in their preferred manner, as stated in their care plan. The staff explained “service users communicate in many different ways, usually a facial expression or body language informs us of whether or not the individual is happy or agrees with the outcome!” Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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): 12,13,17. (Standards 15 & 16 were assessed during the previous inspection.) Service users participate in activities appropriate to their age, peer group and cultural beliefs as part of the local community. Dietary needs of service users are well catered for with a balance and varied selection of food available that meets individual’s dietary requirements and choices. EVIDENCE: Staff explained that Service users are encouraged, in line with their care plan and risk assessments, to participate in social activities, both within the home and the community. Records of activities are recorded in the individuals care plan and daily records, these include daily activities such as art, games, awareness of the world by looking at stories in newspapers/magazines, listening to stories on audio tape, cooking and nutrition, as well as visits to the cinema and shopping. Staff confirmed they often support service users in going to the pub, or to a local café for a cup of tea. Staff record on a daily basis what each service user has participated in and whether or not the service user enjoyed or benefited from it, this information then feeds into the service users review where a timetable of activities is discussed and devised. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 12 Care plans reflect the individuals cultural beliefs and individuals sexual preferences, the staff explained at present service users do not wish to partake in relationships, other than friendships outside the home. Should the need arise, service users would be fully supported and staff would follow the homes policy on personal and sexual relationships. Staff confirmed they would obtain support from outside agencies (an advocate) should it be required for any service user. The inspector witnessed the visitors book that detailed family and friends visits to the home. Staff reported there are no restrictions on visiting, unless stated in an individuals care plan. The inspector saw the home’s menus displaying a variety of nutritious meals, which included an alternative. Stock areas and fridges were well stocked with fresh and tinned produce, the menu displayed a variety of nutritious meals. The inspector saw a record of individual’s food intake, staff said this helps them to ensure service users are receiving a balanced diet that they enjoy. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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): 18,19 (Standard 20 was assessed during the previous inspection.) Service users receive personal support in the way they prefer and require. Comprehensive procedures ensure service user’s physical and emotional health needs are met. EVIDENCE: The care plans and risk assessments states how the individual wishes to receive their personal support and are reviewed on a monthly basis or as needs change. Daily records comment on individuals daily activities, physical and emotional health and behaviour, records of visits to outside agencies, such as doctor, dentist, optician are kept on the individuals file, this enables the home to monitor and track the information recorded. The inspector sampled two care plans, both included guidance of how to meet the individual’s physical and emotional health needs, and most recent visits to healthcare professionals. One member of staff said “I find the information in the care plans very useful and detailed, it includes trigger factors to be aware of for behaviour and seizures, and what to do about an incident when it occurs. I have worked in many homes, and this is by far the most organised and informative, enabling me to do my job.” Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 14 Staff confirmed they receive a variety of training to support service users, including, communication, awareness of disabilities, diabetes, epilepsy and care planning. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 15 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 (Standard 22 was assessed during the previous inspection.) The home has satisfactory procedures for protecting service users’ form abuse. EVIDENCE: Staff follow comprehensive care plans and risk assessments for a service users who may harm others, the inspector found the records to be eligible and complete, staff confirmed the details in the care plan and risk assessments enable them to carry our their role effectively. The inspector saw the homes adult protection procedure, which includes the Department of Health “No Secrets” guidelines. The home also have copies of Hampshire’s guidelines for the Protection Of Vulnerable Adults. Staff confirmed they have attended abuse awareness training, and that abuse was covered during their comprehensive induction, however the training records and staff files were not available. Staff said they discuss issues surrounding abuse policy and procedures at their monthly staff meetings with their line manager supervisions, and confirmed their awareness of the procedure and where to find it should it be required. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 16 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 (Standard 30 was assessed during the previous inspection.) The home presents as a homely, comfortable and safe environment for service users to live in. EVIDENCE: The inspector looked at all communal areas and two bedrooms, all area appeared clean, warm and were well maintained, brightly decorated to meet the preferences of the service users. The walls displayed pictures of service users participating in activities, with family/friends and on an individual basis, which appeared to give a ‘homely’ feel to the home. Bedrooms were also brightly decorated and had posters and the service users photographs on the walls, and other personal effects. Staff explained service users are encouraged to furnish their room to their taste with personal belongings, furniture and pictures to make it feel like home. The garden appeared well maintained and is accessible to service users. Risk assessments are in place to minimise risks regarding the building and garden. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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): 32,34, (Standard 35 was assessed during the previous inspection.) Staff records were not available for the inspector to fully assess these standards. EVIDENCE: Staff files were not available for the inspector to sample, therefore the home is requires to ensure staff records are available for CSCI inspection in the manager’s absence. The inspector sampled the homes staff rota which showed adequate cover during the day and night, the inspector asked the member of staff if they felt confident being in charge during the inspection as the manager was on annual leave, the staff confirmed although she has only worked at the home for seven months, she is experienced and has almost completed her National Vocational Qualification (NVQ) level 3 in care. staff confirmed they feel adequate staff are on duty to meet the service users needs, however one staff said more drivers would enable service users to go out more, she confirmed she was soon to take her driving test, so to were two other staff, which would mean the home had five drivers for two Service users. therefore the manager is required to ensure records are available for inspection at any time. One staff member said “ I feel I have adequate training and experience in order for me to carry out my job, I can just ask if I want training, I don’t have to wait until a meeting or my supervision.” Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 18 One staff confirmed they had received all mandatory training. Staff explained “we work well together as a team, during staff meetings we talk openly and share ideas and support one another, this helps us meet the needs of all service users.” Staff said they are working towards their National Vocational qualification level 2 and 3 and the Certificate In Working with People with Learning Disabilities. Staff confirmed they felt the recruitment process was robust, and that they were not confirmed in post until the necessary checks had been completed. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 19 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): 37,42 (Standard 39 was assessed during the previous inspection.) The home has a registered manager who runs the home in the best interests of the service users. The health, safety and welfare of service users are fully protected. EVIDENCE: The manager is registered with The Commission for Social Care Inspection (CSCI) The inspector receives monthly reports from the homes responsible individual when they visit the home, in which service users are consulted on their views of the home, to meet regulation 26 of the Care Standards Act (CSA). The member of staff was not sure if a service user survey had guide been distributed recently. Staff confirmed quality issues are discussed on a one to one basis at their supervision and within staff meetings. The inspector saw the homes maintenance file which is used by staff to report any faults they find, staff confirmed a weekly check is completed on all areas Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 20 within the home to check for faults or potential hazards, the inspector saw records of this. Staff confirmed the home have a dedicated maintenance person who deals with requests as they are made. Staff said they feel they receive adequate training on health and safety issues, including moving and handling training, first aid, food hygiene and Control Of Substances Harmful to Health. However, staff files containing certificates and training plans were not available. The home has risk assessments in place for the building and safe working practices for staff. Certificates showed the maintenance of services within the home were up to date. Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mullion Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000011679.V273134.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA32 Regulation 17 (3) (b) Requirement The home must ensure staff records are available for CSCI inspection in the manager’s absence. The home must ensure staff records are available for CSCI inspection in the manager’s absence. Timescale for action 20/01/06 2 YA34 17 (3) (b) 20/01/06 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 Mullion DS0000011679.V273134.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Mullion DS0000011679.V273134.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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