Inspection on 17/01/06 for Mythe End House

This inspection was carried out on 17th January 2006.

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

Other inspections for this house

Mythe End House 14/09/06

Mythe End House 17/06/05

Mythe End House 31/01/05

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 Mythe End House Mythe Road Tewkesbury Gloucestershire GL20 6ED Lead Inspector Mr Simon Massey Unannounced Inspection 17th January 2006 01:00 Mythe End House DS0000061857.V279535.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 Mythe End House DS0000061857.V279535.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. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mythe End House Address Mythe Road Tewkesbury Gloucestershire GL20 6ED 01684 299272 01684 299272 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) Kentwood Ltd Miss Maria Nicholls Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the two bedrooms on the upstaris floor with their own staircase are only accommodated by service users that have been risk assessed as being able to safely access this accommodation 17th June 2005 Date of last inspection Brief Description of the Service: Mythe End House is a care home for seven adults with learning disibilities that have complex needs. The home is set in large grounds approximately a mile from the town of Tewksbury. The accommodation is spacious and is spread over three floors. The home is annexed to another registered home that is run by the same organisation, Kentwood Care. Both have their own grounds and entrance. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 3 hours on Tuesday 17th January 2006. The inspector met six staff members and all of the service users. On the day of the inspection all the management were undertaking training away from the home. This meant that some information and documentation was not available, as it was securely stored in the manager’s office. Records and documentation relating to health and safety, medication, care planning and service user activities were examined. An inspection of the environment was also carried out. For a fuller overview against the National Minimum Standards, readers are referred to the two previous inspections that have been completed at Mythe End House. What the service does well: What has improved since the last inspection? No specific areas of improvement were identified during this visit. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 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. Mythe End House DS0000061857.V279535.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 Mythe End House DS0000061857.V279535.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): These standards were not inspected during this visit. EVIDENCE: There have been no admissions to the home since the previous inspection. Mythe End House DS0000061857.V279535.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 Care planning and risk assessing help the staff team to support service users follow individualised routines and activities. EVIDENCE: The full care plans were not available for inspection at this visit but an examination of some of the daily recording was undertaken. The daily personal files contain descriptions of events and activities and information about the response of the service user to anything they may have participated in. The files contained details of appointments, visits from relatives, activity records and also monthly summaries of how the previous four weeks have gone for each person. These files also contain “body charts”, which provides diagrammatical evidence of any injuries that service users may have incurred. The files contain the explanations for how any injuries may have happened. A record is also kept of food intake and body weight. All records were correctly dated and contain a reasonable amount of detail. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 10 Each person has a number of risk assessments in place and these were dated and reviewed at the correct intervals. Staff were able to explain how they use the risk assessments to help people participate in activities, both in the home and in the community. Mythe End House DS0000061857.V279535.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): 11,13 & 14 The home identifies activities that may be of interest to service users and supports them to make choices about what they wish to participate in. The home is committed to accessing facilities in the community and supporting service users to develop their skills and interests. EVIDENCE: People’s routines are flexible and reflect their individual needs. Activities are planned for the week and are written out on a large white board, which helps the planning of staffing cover. The home has a senior staff member who coordinates day-care activities and also researches future activities, events, college courses and other opportunities that may be of use or interest to the service users. This system has been further developed with the recent introduction of a number of additional options for service users to choose from. These include screen-printing and some college courses. Staff also now record the cover for the week on an adjacent white board, which provides a very good visual Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 12 picture of how activities will be supported. This also helps identify any shortfalls in staffing which may require alternative arrangements to be made. On the day of the inspection all service users had participated in two activities during the day. People were also observed watching videos, playing on computers, cleaning their bike and also relaxing in the living room interacting with the staff on duty. Staff recognised the signs of a service user who was becoming agitated, and this situation was dealt with quietly and effectively by the staff on duty. Service users were observed using the communal space in the home as well as the grounds, and also using their own bedrooms to entertain themselves using the facilities and equipment that have been provided. Mythe End House DS0000061857.V279535.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): 20 The system for storage and administration of medication is appropriate to the needs of the service users. Some minor changes to the recoding system are required to ensure that stock control is properly maintained. EVIDENCE: The medication storage and administration system was examined and found to be generally in order, though some minor shortfalls were identified. The cabinet contains a large store of an anti-depressant in liquid form. These containers need to be numbered in the sequence in which they are to be used and dated when the bottle is opened. A square should be marked on the administration record at the date and time when the new bottle is opened. The auditing system will then be able to demonstrate whether the correct amount of liquid is in the bottle. The home should also ensure that no more than a months supply is in place at a time. Some creams and homely remedies are stored in the cupboard and there is need for all of these to have the date they are opened written on the packet or box. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 14 A large bottle of spirits was also being stored in the cupboard and was marked as being for “cooking purposes only”. This needs to be stores in an alternative location. None of the service users are assessed as being able to self-medicate. Al list of staff assessed as competent to administer medication is provided in the medication-recoding book. The previous inspection produced a requirement about staff training in relation to the use of rectal diazepam. Prior to this inspection the manager had informed the Commission of satisfactory arrangements that have now been put in place. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 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): These standards were not inspected in detail during this visit. EVIDENCE: All staff are required to undertake specific training called CALM, which relates to the managing of challenging behaviours. The focus of this training is deescalation and low arousal techniques. Staff also receive training in restraint techniques as part of this package. Records in the office and discussion with staff showed that people are up to date with this training and are confident and aware of its relevance in the home. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 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): 24,25,26,28 & 30 The home provides spacious and homely accommodation, which helps create a comfortable and safe environment for service users. EVIDENCE: All parts of the home were seen during this visit and the environment was well maintained, clean and homely. All bedrooms are personalised and reflected the individual interests and personalities of the occupants. Service users were observed making use of the space and facilities in their rooms. One service user who will not tolerate any furnishings in their room continues to have the room monitored and repaired regularly by the staff and the maintenance team. Adaptations have been made to the en-suite to minimise the risk of self-harm and clothes are securely stored in the wardrobe. This is also documented in the personal file. Mythe End House DS0000061857.V279535.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): 31,33 & 36 Staffing numbers help ensure that the needs of service can be met. Staff awareness of their roles and responsibilities contribute to the effective team working at the home. Regular formal supervision of staff could improve staff development and promote understanding of the role of the care staff. EVIDENCE: On the day of the inspection there were sufficient staff on duty to meet the needs of the service users and examination of staff rotas showed that these levels are maintained. This is done with the additional help of relief staff and the occasional use of agency staff. Staff were observed interacting appropriately with service users and seemed clear of their responsibilities. Staff were observed planning for the shift and ensuring that arrangements were in place to facilitate the evenings activities. The home has had four staff meetings since May 2005 and the minutes from these show that arrange of issues are discussed and input and guidance is provided to the staff team on a variety issue relating to practice and care. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 18 The records of staff supervision showed that not all staff are receiving regular supervision sessions, with several staff not having had any supervision for several months. The standards recommend that staff receive supervision every six to eight weeks and a requirement has been made in relation to this. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 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 The management standards were not inspected in depth during this visit but service users appeared to be benefiting from an effectively run home. Regular testing of fire equipment and water temperatures is needed to ensure that service users are protected from potential hazards. EVIDENCE: At the time of this inspection the acting manager was going through the process of registration. When the Commission receives confirmation of certain training that must be undertaken, it is anticipated that registration will be completed. At the time of this visit all the management were away from the home undertaking training, which made some records and information unavailable to the inspector. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 20 The home appeared to be running effectively on the day of the inspection, with activities taking place, appointments being kept and staff planning for the evening. Examination of fire records showed that that there was shortfall in recoding of tests for the first part of January 2006. Fire alarms must be tested weekly and these tests recorded. All equipment had been serviced and records kept. All other safety tests have been completed. A number of hot water outlets were checked and some of these were found to be too hot and require adjusting. A number of environmental risk assessments were seen and these were up to date and had been appropriately reviewed. Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 x ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 X 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 x 3 x X X X 2 x Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO 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 YA19 Regulation Requirement Timescale for action 28/02/06 2 3 4 YA36 YA42 YA42 12(1(a)&13(2) The home must address the issues relating to medication administration outlined in the report 18(2) Staff should receive regular formal supervision 23(4)(a) The home must ensure that fire testing is completed weekly and recorded 13(4) (a) The home must test the water temperatures in the bathrooms and en-suites regularly and ensure they are within safe limits 28/02/06 28/02/06 28/02/06 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 Mythe End House DS0000061857.V279535.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Mythe End House DS0000061857.V279535.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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