Inspection on 03/10/06 for RNID Mulberry House

This inspection was carried out on 3rd October 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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

RNID Mulberry House 24/01/06

RNID Mulberry House 31/01/05

RNID Mulberry House 23/08/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 RNID Mulberry House Mulberry House 70 Lichfield Street Walsall West Midlands WS4 2BY Lead Inspector Lesley Webb Unannounced Inspection 3rd October 2006 10:30 RNID Mulberry House DS0000020840.V314250.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 RNID Mulberry House DS0000020840.V314250.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. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service RNID Mulberry House Address Mulberry House 70 Lichfield Street Walsall West Midlands WS4 2BY 01922 615218 F/P01922 615218 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.rnid.org.uk RNID Care Services Caldmore Housing Association Mrs Christine Violet Beckett Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Physical disability (6) of places RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006. Brief Description of the Service: Mulberry House offers residential placements for up to six service users who may have a mental disorder (excluding learning disability or dementia) and who may also be deaf or hard of hearing. The premises are made up of 2 selfcontained bed-sits and 4 flat, set within a large detached property. The offices, kitchen and sleeping in room are attached to, but are separate from the main house. The 4 flats consist of a bedroom, sitting room, kitchen and bathroom/shower. There is a separate bathroom on the ground floor for service users who prefer to bathe rather than shower. Also on the ground floor is a shared sitting room leading directly onto the patio. The home has a goodsized garden and off road parking to the rear of the property. A laundry is fitted with a coin operated washing machine and dryer. All of the service users sign to say they agree to any profits from this facility to go into the service users social fund. The home is located near to the centre of Walsall, close to many shops and facilities. There is a main road to the front of the building with many bus routes to other parts of the West Midlands and the local Arboretum faces the home. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All the service users and some of the staff at Mulberry House are either deaf or hard of hearing so the inspector arranged for an interpreter to accompany her on the un-announced inspection. They arrived at 10.30am and spent 3 hours interviewing in private 2 of the 5 service users in order to obtain their views and opinions on service provision and life at the home. The interpreter then left with the inspector remaining at the home until 6.00pm. During that time the inspector sat in and observed a staff meeting, indirectly observed practices, toured the building and looked at records before giving feedback to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking 3 individuals care provided at the home. For example the people chosen consisted of new and established service users, with differing communication needs and from various cultural backgrounds. Prior to the unannounced inspection a pre-inspection questionnaire and service user surveys were sent to the home in order that additional information could be gained. These documents were also used when forming judgements about care provision at the home. Information included in the pre-inspection questionnaire includes fees charged. These range from £703.09 to £1170.85. All comments recorded in the service user surveys were of praise for the staff and service provided, with no negative comments regarding any area of support provided. By the end of the visit the inspector was satisfied that the home offers an excellent service and would like to thank everyone for his or her co-operation and assistance during the visit. What the service does well: Mulberry House has many strengths and has a sustained track record of delivering good performance and managing improvement. Strengths include providing prospective people to this service and their representatives with information needed to choose a home that will meet their needs. They ensure needs are assessed in full and a contract is provided which clearly tells people about the service they will receive. All information is provided in alternative formats including picture, large print and photograph. The home should also be commended for its efforts to involve people in decisions about their lives, encouraging them to play an active role in planning the care and support they RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 6 receive. Person centred planning is embedded in the culture of the home, with all systems and structures based on this principle. For example shopping, cooking, financial and medication management is all completed on an individual basis with staff supporting where needed. People who use this service are able to make choices about their life style, and are supported to develop their life skills, for example paying of bills, cleaning of individual flats and supporting to take control of their lives with the aim of living independently in the wider community. Social, educational, cultural and recreational activities as well as being based on individual needs and choices are managed in such a way that individuals needs are balanced with others living at the home so that many one to one activities take place but also group activities are planned in order to help build relationships. The principles of respect, dignity and privacy are put into practice throughout the home. For example all service users are deaf and each flat has a doorbell/light system so that staff do not enter without a persons permission. Staff at the home have a very good understanding of supporting people to raise concerns and make complaints, with all people living at the home praising staff in this area. As the home is designed to provide small group living with each person having their own flat/bed-sit the environment stimulates maximum independence in a discrete non-institutional environment. People who live at the home are fully involved in decisions about the décor and any changes to the accommodation. In addition to this there is a selection of communal areas both inside and outside of the home, which means people have a choice of places to sit quietly or to be actively engaged with other people who use the service. Mulberry House has excellent recruitment procedures that have the needs of the people who use the service at its core. The home is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy. The result of this is a diverse staff team that has a balance of all the skills, knowledge and experience to meet the needs of service users. The management of the home is excellent. There is strong evidence that the ethos of the home is open and transparent. The views of both service users and staff are listened to and valued. What has improved since the last inspection? Since the last inspection secondary dispensing of medication has ceased, with an alternative monitoring system implemented and a policy relating to secondary dispensing has been implemented. Also all requirements made by the fire department have been actioned, steps at the front and rear of the building have been highlighted, downstairs bathroom has been redecorated and liquid soap, paper towels and personal protective equipment have been provided in the laundry room. Also all staff have signed a declaration stating they are fit for the role they undertake, the fire risk assessment has been reviewed to include phased RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 7 evacuation and risk assessments have been completed for all COSHH (Control of substances hazardous to health) products. The manager has also developed a quality assurance system that is specific to the service. This includes setting aims and objectives for future improvements and planning. 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. RNID Mulberry House DS0000020840.V314250.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 RNID Mulberry House DS0000020840.V314250.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5. The overall outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. Prospective people to this service and their representatives have the information needed to choose a home that will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: The inspector found an abundance of evidence that demonstrates people are fully supported when making decisions on suitability of the home. For example the homes statement of purpose and service user guide are very detailed and contain information above what is required in the National Minimum Standards and is very specific to the resident group. The service user guide is in alternative formats including large print and includes the use of photographs. This and other information is displayed on the service users notice board and contained within each persons file as well as being on display in the office. It was also pleasing to find evidence that people already using the service have been involved in the compilation of the service user guide, giving their comments and experiences of living at the home. All files sampled contained full and comprehensive needs assessments. These included information from a range of sources including other relevant professionals such as social workers, CPN’s (community psychiatric nurses) and clinical psychologists. It was also pleasing to find evidence on all files RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 10 sampled of service users being fully involved in the assessment process and that assessments are completed in relation to compatibility with others already living at the home. Records also confirm that service users spend time at the home prior to moving in, including overnight stays in order that they can meet other users, staff and to help them become familiar with their surroundings. Contracts of residency were also found to be in place on files sampled, all of which have been signed by the service user and the manager of the home. These contain all information as listed in the National Minimum Standards. Observation of care practices, discussions with service users and staff confirm that the home meets the needs of people living there. As one member of staff explained when asked how the home makes sure all the different needs of service users are met, “the needs are various, communication is main problem, have to do drawings, role play to help them understand, find out their views, use sign language. You have to form relationships before you can be sure you are meeting all their needs. Its important to make sure needs are assessed in full and to find out as much information about a person before they move in”. RNID Mulberry House DS0000020840.V314250.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. The overall outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The inspector found that the key principles of the home for delivering a quality service are based on the belief that people should be able to take control of their lives. An abundance of evidence demonstrates staff are strongly committed to supporting all service users to make informed decisions, understand the range of options which are available to them and have the right to take responsible risks. All care plans sampled contained evidence that they have been developed in partnership with each service user and all clearly set out aims and goals. Person centred planning is embedded in the culture of the home, with plans based on individual needs and capabilities, focusing on development of skills and future aspirations of each individual. Daily observations and records are constructed in such a way that they correspond to each relevant plan of care in order that detailed monitoring and reviewing can take place. The only area that the inspector RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 12 found requiring further development is the introduction of a moving to independent living care plan. Many care plans are in place for specific areas of support required to achieve independence however none covered all aspects of this process. As this is one of the main aims of the service the manager agreed this would further enhance systems already in place. All files sampled also contained risk assessments that work in conjunction with each specific plan of care. As the aim of the home is to develop skills so that people can move to independent living in the community management of risks takes this into consideration. For example one persons file contained a care plan and risk assessment for shopping and cooking their own meals and another’s going to the bank and paying of bills. Staff that the inspector spoke to demonstrated detailed knowledge and understanding of risk management explaining the process, including offering training to individuals in order that risk is managed. As in previous inspections the home is proactive in encouraging and supporting service users to make decisions. Regular residents meetings occur where not only issues relating to the home such as staff and new policies are discussed but set as regular items on the agenda is world news and news in the deaf community. Many policies and procedures are in picture format and large print including confidentiality, consent forms, the house rules and fire evacuation systems. There are also many documents displayed informing of advocacy details and other support networks. As one member of staff explained, “talk about choices e.g. religion, meals, most have never been given choices before so have to encourage. Talk and suggest and explain”. RNID Mulberry House DS0000020840.V314250.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. The overall outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 14 As in previous inspections the inspector found that staff support service users to maintain family links and friendships inside and outside the home, subject to individual’s choice and care plans / contracts. The service users choose whom they see inviting visitors either to the communal lounge or if privacy is required their flats/bed sits. Due to the service users who live at Mulberry being so independent many meet people and make friends with others who do not have a disability. Staff confirmed to the inspector their understanding of supporting people to develop and maintain intimate personal relationships with people of their choice, and gave examples of how they had put this knowledge into practice. For example one member of staff stated, “most have good family contact, one person visits family every Saturday. One refuses we have to respect that. Some used to live here and now come back to visit as have formed friendships, we are here to support in any way they need, can be writing a letter or making a phone call”. All service users that the inspector spoke to confirmed that staff help them when needed. The service users take responsibility for housekeeping tasks, cooking, cleaning their own rooms and laundry. There is unrestricted access to the communal parts of the home. Each of the service user flats have flashing lights connected to the doorbell in order that staff only enter after gaining an individuals permission. All service users have keys to their flat, front door of the building and rear, with staff using a separate entrance to the building. Service users informed the inspector that routines are flexible within the home and staff respect their rights. For example one service user stated, “staff are good, don’t come in my flat unless I say its ok, they help me but leave me alone when I tell them to”. All the flats and bed sits within the home have their own cooking facilities as aids to independence, with service users preparing and cooking their meals on an individual basis. Staff assistance is given depending on each service users needs. In addition to this there is a communal kitchen where meals are prepared and cooked for group social activities. Mealtimes are relaxed, unrushed and flexible to suit service users’ activities and schedules. Evidence was supplied to the inspector that demonstrated that menus meet dietary and cultural needs with staff demonstrating understanding of nutritional assessments in place for individuals. The inspector found on all files sampled records that form care plans for identified needs in relation to education, social and development skills. Activity timetables are in place that includes domestic skills support and social activities with outcomes of these recorded in detailed daily records that demonstrate the activity timetable is adhered to. When talking about activities one service user explained, “I go to work, cooking chopping onions makes me cry and laugh” and another “Going to Walsall College to cook and building. Go for a drink at pub and the deaf club. Lots of friends there lots of deaf people”. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 15 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 and 20. The overall outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Improvements to some medication practices will further enhance an already good system. EVIDENCE: The home has comprehensive policies and procedures for all aspects of medication. Since the last inspection the practice of secondary dispensing has ceased. All medication and records viewed by the inspector were found to be in order apart from the home’s need to clarify ‘as directed’ on pharmacy labels and to ensure full and detailed recordings for hand written instructions on MAR sheets. It was also noted that the homes medication policy for training makes no reference to staff requiring accredited training. The home uses the Boots Monitored Dosage System for prescribed medications. As part of this service the pharmacist visits the home every three months to complete audits and offer advice. All service user files sampled by the inspector contained medication risk assessments and consent to either self medicate or receive assistance from staff. Self-medication assessments were found to be very RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 16 detailed and based on each person’s capabilities. All staff hold accredited medication training certificates. All service users files sampled evidence that the health needs of service users are appropriately managed. Records include visits to dentist, opticians, nurses, opticians and chiropodists. Other records include health reminder charts; lists of current medication, care plans for the management of health needs and consent to medication. It was also pleasing to be informed that the local general practitioner has arranged for interpreters who are independent from the home to be present when service users have appointments, this promoting and protecting service users rights to confidentiality and privacy. Practices observed confirm that service users are supported to be independent and responsible for their own personal hygiene and personal care. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The overall outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns, and have access to a robust and effective complaints procedure. Some policies require further work to ensure people are protected from abuse and have their rights protected. EVIDENCE: When interviewing service users everyone was able to name someone they felt comfortable to talk to if they wanted to make a complaint or if unhappy about treatment. Compliments made about staff include, “I would tell L, staff help you, they are all good” and “I would tell staff, happy to tell they are good”. The home has policies and procedures for complaints and the protection of vulnerable adults. Further work is required with some of these, for example the complaints policy states it was last updated April 2004. It gives details of both oral and written complaints, stating ‘if complaint cannot be dealt with at local level, between the complainant and the home then the case should be referred to the CSCI or supporting people team’. This needs to be reviewed and amended to comply with the Care Home Regulations 2001. The procedure makes reference to CSCI but does not include address. The inspector was shown a new complaint form in British Sign Language easy read making it more accessible to service users. The Royal National Institute for the Deaf adult protection policies and procedures were found to be signed by 8 of the 12 staff employed at the home. It states last updated August 2004. The policy states ‘managers responding to potential abuse situations must follow the guidance provided by the relevant local authority’ but these are not available at the home. The inspector is also concerned that the procedure states ‘line manager assess information and make decision RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 18 whether to refer to social services’ and ‘if information is unclear, carry out risk assessment set review date and report to regional director’. These instructions do not comply with the Care Home Regulations 2001 nor do they follow local authority adult protection guidelines. Discussions with staff demonstrated to the inspector their knowledge and understanding of abuse and their role to protect, for example one member of staff stated, “we have forms, encourage to talk to manager or key worker. We have various choices, also have whistle-blowing policy. If we see behaviour has changed, talk to them give time to talk. If any suspicion staff suspended immediately. If out in the community being aware, we have to risk assess to improve and understand”. 8 of the 12 staff at the home have undertaken adult protection training with the local authority, with the remaining people booked to undertake this on 23/11/06. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 19 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 and 30. The overall outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, generally well-maintained and comfortable environment that encourages independence. EVIDENCE: The inspector was pleased to find that the majority of requirements identified in the previous inspection have been met or part met. The exterior of the premises is still to be redecorated however arrangements for this are now in hand. Requirements made by the fire department in 2004 have been acted upon, an investigation into the watermarks on the ceiling in the staff sleep-in room has been undertaken with work in the process of being arranged to repair the ceiling, yellow lines have been put on all exterior steps at the front of the building so that people are aware of potential hazards and the downstairs bathroom has been decorated. After touring the premises the inspector found that generally it is maintained to an acceptable level. Attention is required to remove the bed frame in one flat, repaint one bedroom and repaint the walls on the stairs and landing by the office. Risk assessments and data sheets in place for all products in the COSHH (control of substances hazardous to health) cupboard. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 20 The manager states that the communal kitchen is going to be refurbished this year. When looking around the building the inspector found that the training room is used for storage with the manager stating that service users choose not to use this facility. This was discussed in detail. The inspector recommends that this room be evaluated with alternate uses investigated. The home has a separate laundry room that has a washing machine (with disinfection programme), hand washing sink and dryer. All policies and procedures relating to the control of infection were found to be located in the main office with copies displayed in the laundry as aids to education for service users (the majority of whom do their own laundry). A detailed maintenance, development and renewal programme for 2006/07 was viewed. This includes replacement of carpets, redecoration of many areas, purchase of new furniture and equipment. Some was found to be actioned and those that had not documented reasons why. For example failed electrical testing or awaiting repairs to roof before decoration of particular areas. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 21 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 and 35. The overall outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions and to support the smooth running of the home. EVIDENCE: A previous requirement to maintain medical declarations for staff is now met. 3 recruitment files were sampled. All contained documentation required by regulation apart from copies of contracts of employment and in one case a job description. The home has good recruitment procedures that clearly define the process to be followed. Staff that the inspector spoke to confirmed that they were informed of all stages when being recruited and the home was robust in the following of its procedures. Records confirm that the use of agency workers is not practiced at this home. As in previous inspections the home should be commended for its training and development systems and structures in place. A Senior member of staff is responsible for ensuring the homes training and development programme is maintained and the inspector found that all staff have individual training and development assessments completed that not only detail mandatory training needs but also training and development requirements that are linked to RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 22 service users individual needs and care plans. All staff receive structured induction and foundation training that meets Sector Skills specifications, with the appropriate records maintained. The National Minimum Standards state that staff should receive at least five paid training days per year, however at Mulberry House staff receive payment for all training they attend. Courses that staff have attended include bereavement, risk assessment, challenging behaviours, autism and alcoholism. Staff that were interviewed confirmed the organisations commitment to providing training and development, for example one member of staff stated, “everyone does core skills and training specific for your own role. Training is discussed in supervision and appraisal”. Records also confirm that 3 staff have completed NVQ level 2 or 3, 3 are in the process of completing this qualification and the remaining 3 staff will be enrolling shortly. Discussions with staff and observations confirm that staff have the appropriate skills and knowledge to support service users. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 23 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): 37,39 and 42. The overall outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The registered manager has above the required qualifications and experience, is highly competent to run the home and meets its stated aims and objectives. She works to continuously improve services and provide an increased quality of life for service users. Through observations and discussions with service users and staff the inspector found that there is a strong ethos of being open and transparent in all areas of running of the home and that the manager is person centred in her approach, and leads and supports a strong staff team who have been recruited and trained to a high standard. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 24 It was pleasing to find progress has been made regarding requirements identified in previous inspection relating to further development of the quality assurance systems within the home. The manager has devised and implemented her own system as RNID (Royal National Institute for the Deaf) is still in the process of developing a corporate one. This includes a good written policy and procedure that states an aim of ‘Setting new objectives to allow for progression, growth and development’. The new system also includes an annual audit. The new system was discussed with the manager who agreed further development could take place to collate other monitoring tools such Regulation 26 reports, service user reviews and importantly service user and their representatives views. The inspector was pleased to find that the majority of staff working at the home hold up to date fire, first aid, food hygiene, manual handling, health and safety and infection control certificates. Safe working practice risk assessments were found to be in place and all accidents, injuries and incidents were found to be recorded and stored appropriately in accordance with the Data Protection Act. The fire risk assessment has been reviewed since the last inspection and individual assessments for each service user implemented, however upon examination these require further work to ensure they are completed based on each persons capabilities. COSHH data sheets were found to be in place for all substances used in the home along with risk assessments. All other records relating to health and safety management were found to in order apart for the need for a Legionella assessment as records state a check was undertaken March 2005 but that no initial assessment or follow on checks have occurred. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 25 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 4 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 4 12 3 13 4 14 3 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 4 3 X X 2 X RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 26 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 2 Standard YA6 YA20 Regulation 15 13(2) Requirement Care plans for moving on from the home must be introduced that contain aims and goals. ‘As directed’ instructions on pharmacy labels must be investigated. Hand written recordings on MAR sheets must contain the same information as per pharmacy dispensing labels. The medication policy for training requires reviewing to include the need for staff to undertake accredited medication training. The complaints policy must be reviewed and amended to comply with the Care Homes Regulations 2001. The adult protection policy must be reviewed and amended to comply with the Care Homes Regulations 2001. The home must obtain a copy of the local authority adult protection procedures. The exterior of the premises DS0000020840.V314250.R01.S.doc Timescale for action 01/12/06 01/11/06 3 YA22 22 01/12/06 4 YA23 13(6) 01/12/06 5 YA24 23(2)(b) 01/01/07 Page 27 RNID Mulberry House Version 5.2 must be redecorated Requirement originally made January 2004. The home must investigate the watermarks in the sleep-in room and make any necessary repairs (Part met – Requirement originally made January 2006). The bed frame must be removed from the named service users room. The named service users bedroom must be redecorated. The walls on the stairs and landing must be repainted. A copy of contracts of employment and job descriptions must be maintained on each employees file. Further development of the quality assurance system must take place. This must include: The views of families, friends and stakeholders in the community must be sought as part of the quality assurance system - Requirement originally made January 2005. 8 YA42 13(3)23(4) Individual assessments of risk must be completed for each service user and incorporated into the homes fire risk assessment (Part met – Requirement originally made January 2006). A Legionella assessment must be undertaken by a qualified person with appropriate testing RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 28 6 YA34 Sch4(6)(f) 01/12/06 7 YA39 24 01/01/07 01/12/06 of water. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations It is recommended that the disused training room be evaluated with alternative uses investigated. RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 RNID Mulberry House DS0000020840.V314250.R01.S.doc Version 5.2 Page 30 - 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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