Inspection on 21/04/08 for The Martins

This inspection was carried out on 21st April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 The Martins Abbingmoor Farm Laxton Road Egmanton Nottinghamshire NG22 0EU Lead Inspector Jayne Hilton Unannounced Inspection 22nd April 2008 10:15 The Martins DS0000071237.V362834.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 The Martins DS0000071237.V362834.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. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Martins Address Abbingmoor Farm Laxton Road Egmanton Nottinghamshire NG22 0EU 01604 864466 01604 864491 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) Oakleaf Care (Newark) Ltd Ian Mosley Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N To service users of the following gender: Male Whose primary care needs on admission to the home are with the following categories: Mental Disorder - not including a learning disability or dementia - Code MD The maximum number of service users who can be accommodated is:10 This is the first inspection of this new service. 2. Date of last inspection Brief Description of the Service: The Martins is a low secure 10 bedded unit and offers places to males with acquired brain injury and neurological conditions who require a clear and comprehensive care pathway. The accommodation provides a lounge with two conservatory areas, a dining area set in 6 acres of grounds and gardens. All 10 single bedrooms have en-suite facilities. The home is owned by, The Oakleaf Care Group. The home is accessible for people with mobility difficulties. Information on fees were not available at this visit. An up to date Service User Guide was viewed on the premises. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people living in the home and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 4 daytime hours and was unannounced. The home was registered in October 2007 and this was the first inspection of the service. Prior to completing this visit the inspector assessed the homes service history including complaints and adult protection referrals, and the Annual Quality Assurance Assessment completed by the registered manager. No surveys were returned by people living in the home or by relatives prior to the inspection. Surveys received on 24th April 2008 were from 3 people who live in the home, seven staff and 1 relative all were very positive in their feedback on the service. The main method of inspection used was case tracking, this is to randomly select people who live in the home and read their care files, examine their private and communal accommodation along with any specialist equipment they require. Their care is tracked to ensure that their needs are being met and that staff, have the skills to deliver the care they need. One person’s care files was examined in detail and two other peoples care file was randomly sampled for information. The people who were “case tracked” were able to help by giving an opinion about the care provided. Three members of staff were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to the people who live at the home. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 6 What the service does well: Outcomes for people living in the home are positive. The key principle of the home is that people using the service are in control of their lives. Staff, are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service confirmed they make their own informed decisions and have the right to take risks in their daily lives. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, appropriate to their peer group, in both the home and the community, and to enjoy all the rights and responsibilities of citizenship. The staff team understands the importance of enabling younger adults to achieve their goals, follow their interests and be integrated into community life and leisure activities in a way that is directed by the person using the service. The service understands and actively promotes the importance of respecting the human rights of people using the service, with fairness, equality, dignity, respect and autonomy all being seen as central to the care and support being provided. The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who use the service who live there. The living environment is appropriate for the particular lifestyle and needs of the people living there and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. Individuals are encouraged to see the home as their own. It is a very well maintained, attractive home and has very good access to community facilities and services. It has a wider range of up to date specialist equipment and adaptations to meet the individual needs of people who use the service. Prospective new residents are assessed before coming to the home to make sure that the home is able to meet their needs. Where risk assessments identify risks faced by residents these are included in care plans to minimise the risk to residents. People living in the home have health action plans in place to ensure their health is monitored and their needs met. Care is provided in a way that promotes the privacy and dignity of people living in the home. Most staff have either completed or are working towards National Vocational Qualification level 2 and regular training is provided, which means that people The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 7 living in the home, are supported by staff who have a qualification in their work and are suitably trained. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. He works to continuously improve services and provides an increased quality of life for residents with a focus on equality and diversity issues and promoting human rights, especially in the areas of dignity, respect and fairness. A relative highly praised the staff team for their support and success in helping their family member make good progress in a short space of time and described the team as ‘invaluable’ What has improved since the last inspection? What they could do better: Five requirements have been set as follows: Make appropriate arrangements to ensure that all staff personal records are available for inspection at all times. This will ensure that we have appropriate access to records to assess if people living in the home are appropriately safeguarded. Take appropriate and Immediate action to ensure that staff are not employed to work at the home without the necessary recruitment checks. This will ensure people living in the home are appropriately safeguarded. Ensure that the Commission for Social care Inspection is notified of any events which, affect, the health and well being of individuals residing in the home as required by Regulation 37. This will ensure that we have appropriate access to records to assess if people living in the home are appropriately safeguarded. Where any limitations are imposed [i.e. door locks immobilised, issue of keys] Care plans must contain appropriate documentation in respect of this. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 8 Obtain the Nottinghamshire Safeguarding Protocols and apply these within the homes own policies for safeguarding. Fourteen good practice recommendations have been made to further improve the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 9 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 The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. For people who are self-funding and without a care management assessment, a skilled and experienced member of staff always undertakes an assessment. The assessment is conducted professionally and sensitively and involves the individual and their family or representative, where appropriate. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The management team may consider the application together with other staff, where all information is shared and views, and comments are listened to and fully debated, before agreement is give for the admission. Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and to help The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 11 them understand how the home is organised and run and the facilities and services available. The allocated staff member will give them special attention, help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. 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 care plans and risk assessments in place were generally detailed and were regularly reviewed. There was some evidence that the service involves individuals in the planning of care, which affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. The service knows and records the preferred communication style of the individual, and will use proven methods that enable the person to lead a full The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 13 life that promotes independence and choice. These could include more communication aides such as photographs and symbols however. Care plans are person centred and are agreed with the individual where possible however two out of three care plans were not signed or fully completed as to why the person could not agree to their plan. Plans are written in plain language, are easy to understand and look at all areas of the individual’s life. They include reference to equality and diversity and address any needs identified in a person centred way. Staff have skills and ability to support and encourage residents to be involved in the ongoing development of their plan. A key worker system allows staff to work on a one-to-one basis and contribute to the care plan for the individual. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. The management of risk is positive in addressing safety issues while aiming for improved outcomes for people. However where there are limitations, such as where bedroom door locks immobilised the decisions has not been made with the agreement of the person or their representative and are not accurately recorded. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services 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. Further development of menus and meal options would improve the lifestyle choices for people in the home. EVIDENCE: The service has a strong commitment to enabling individuals to develop or maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. People who use the service have the opportunity to develop and maintain important personal and family relationships. The staff practices promote The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 15 individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. People residing in the home are involved in meaningful daytime activities of their own choice, or within therapeutic programmes and according to their individual interests, diverse needs and capabilities. They can access and enjoy the opportunities available in their local community, such as using public transport, library services, the local pub, and local leisure facilities. The service is committed to the principles of inclusion and promotes and fosters good relationships with neighbours and other members of the community. Where appropriate people in the home are involved in the domestic routines of the home. They take responsibility for their own room. The menu is varied but there is only one choice on offer for the main meal, although, the menu does inform people they can have an alternative such as jacket potato or sandwiches should they not wish to have the option offered. Although staff acknowledged that people in the home were not fond of Quiche it was being prepared for lunch on the day of the inspection. The cook said the menu had been changed for the future. A copy of the written menu was on the notice board, but this was in small print and not easily accessible for people living in the home. One person said he didn’t know what he was having for lunch, he had not made a choice and as he had liquidised or soft diet, he could not tell whether he was having beef or chicken. Staff were receptive to the issues raised and acknowledged that this was an area for development of pictorial menus and for people to be more informed and be given more choice. The food in the home is of satisfactory quality, well presented and meets the dietary and cultural needs of people who use the service. Staff are trained to help those individuals who need help when eating and are sensitive in their approach. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 16 The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area 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. EVIDENCE: People receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan or health action plan. They give a comprehensive overview of their health needs and act as an indicator of change in health requirements. Personal support is responsive to the varied and individual needs and preferences. The delivery of personal care is individual and is flexible, consistent, reliable, and person centred. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 18 Staff respect privacy and dignity and are sensitive to changing needs. People are supported and helped to be independent and can take responsibility for their personal care needs. Staff listen and take account of what is important to them. Staff members are very alert to changes in mood, behaviour and general wellbeing and fully understand how they should respond and take action. Individuals have access to healthcare and remedial services. Staff make sure that those who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. The health care needs of residents unable to leave the home are managed by visits from local health care services. Residents have the aids and equipment they need and these are well maintained to support them and staff in daily living. Staff have access to training in health care matters and are encouraged and given time to attend seminars on specialist areas of work. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. The home respects and understands the rights of residents in the area of health care and medication. They work with individuals regarding any refusal to take medication. Thought has been given to providing safe but sensitive facilities for keeping medication. The storage temperatures of medication are not being monitored currently and this should be undertaken to ensure it is stored at the correct temperature. Staff work to clear and robust practices when caring for individuals who have degenerative conditions and terminal illnesses. Care plans are person centred and contain clear information about the individual’s wishes, choices and decisions as their health deteriorates. Care staff work to a very high consistent standard and constantly monitor pain, distress and other symptoms to ensure individuals receive the care they need. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, however poor recruitment practices may place people at risk of harm. EVIDENCE: The service has a complaints procedure that meets the NMS and regulations. Some individuals say they know how to make a complaint but others do not. No complaints had been recorded in the complaints file. There are policies and procedures for safeguarding people who use the service but these did not outline the Nottinghamshire agreed protocols. Staff were not familiar with the Nottinghamshire Safeguarding guidance and could not access this. Staff, spoken with were aware of the ‘whistle blowing’, procedures and confirmed they had received training in the topic at induction. Training records viewed supported this. Care plans need to embrace any limitations imposed in respect of bedroom door locks and keys. Recruitment practices by the service were found to be in breach of regulation in that a newly appointed member of staff had started work at the home The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 20 without the appropriate POVA first checks [Protection of Vulnerable Adults list] and references in place. An Immediate Requirement was issued in respect of this to ensure people living in the home were safeguarded. Other staff spoken with at the home confirmed they had undergone the necessary checks prior to commencing work at the home, but no records were available to support this. Staff and records confirmed that staff, have training in physical\interventions and staff said they felt confident in handling any challenging behaviour presented by people living in the home. Incident records were in place, however one incident was reportable under Regulation 37 but there is no evidence that this was notified to CSCI [Commission for Social Care Inspection]. There is a policy for managing the finances of people living in the home and records were in place for one person. Staff spoken with were aware of the position of using advantage cards when making purchases with people living in the home. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area 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 residents to live in a safe, well-maintained and comfortable environment, which encourages independence. Where people are restricted, the appropriate documentation needs to be in place for each individual concerned. EVIDENCE: The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who use the service who live there. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. Individuals are encouraged to see the home as their own. It is a very well maintained, attractive home and has very good access to community facilities The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 22 and services. It has a wider range of up to date specialist equipment and adaptations to meet the individual needs of people who use the service. The environment is fully able to meet the changing needs of people, along with their cultural and specialist care needs. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment are designed to fit within the homely environment. The management has a proactive infection control policy and they work closely with their own staff and external specialists, such as NHS infection control staff, to ensure that infections are minimised. The bedrooms are above-average size, very well designed with en-suite facilities. The fixtures and fittings are of high quality, well maintained and adapted to meet the wishes of the present occupant. Individuals personalise their rooms and can use their own furniture if they wish. All bedrooms promote high levels of privacy and have locks, but these are not all in full working order. All residents should have a key to their own room unless a person centred risk assessment indicates otherwise. There are no lockable facilities provided in bedrooms for people to keep their valuables. There is a selection of communal areas both inside and outside of the home, this means that people using the service have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. There are concerns about the health and safety of people using the kitchen and dining room unsupervised but there was no recorded evidence, which showed this had been fully risk assessed with the involvement of the person. Access should only be limited when the completed assessment indicates such a need. The laundry was not inspected but all staff are trained in infection control and gloves and aprons were seen around the home. Staff were observed wearing protective clothing for tasks in the home. There are no cleaning staff employed at the moment and support staff are therefore undertaking cleaning in the meantime. There was some cobwebs noted in high areas and the staff/visitors toilet/shower area requires a good clean. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. 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 service. Recruitment practices could not be fully assessed due to records not being available for inspection. EVIDENCE: People are generally satisfied that the care they receive to meet their needs, but there are times when they may need to wait a short time for staff support and attention. There are enough qualified, competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas take into account the needs and routines of the people using the service. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the NMS. The manager is aware that there are some gaps in the training programme and plans to deal with this. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 24 The service is also able to recognise when additional training is needed, but is not always in a position to provide this training. There is limited understanding of the person centred way of delivering care and support, but this is through lack of opportunity rather than a negative or ‘blinkered’ approach. All staff are clear regarding their role and what is expected of them. Staff supervision records were viewed and staff confirmed these were an accurate record of this. The service has a recruitment procedure that meets statutory requirements and the NMS. However it was found that the procedure is not always followed in practice. The staff recruitment files were not available for inspection, therefore Urgent Action is required to ensure these are accessible at all times for inspection. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The 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 manager is qualified and has the necessary experience to run the home. The systems in place were well organised to accommodate regular audit. The manager trains and develops staff who are competent and knowledgeable to care for the residents. The service focuses on the individual, takes account of equality and diversity issues, and generally works in partnership with families or close friends, as appropriate, and professionals. The manager is improving and developing systems that monitor practice and compliance with The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 26 the plans, policies and procedures of the home. More work is needed in this area. There was no evidence of service user, relative or professional surveys yet being undertaken but there was evidence of House meetings and consultation with service users. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last six months, or how it is planning to improve. The AQAA gives us some limited detail about the areas where they still need to improve. The ways that they are planning to achieve this are briefly explained. The data section of the AQAA was completed. The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets health and safety requirements and legislation. Windows have restrictors fitted and radiators are low surface temperature type. Records were seen for water outlet temperatures and weekly fire checks are in place. The fire risk assessment and five yearly electric circuit test certificate was not available however. Records were seen in preparation for portable electric appliance testing, but this did not evidence the date carried out. Records for one person were in place in respect of finances; these were viewed and found to be satisfactory. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 27 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 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 2 2 X The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 28 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 17 schedule 3.3[q]] 17,19 Requirement Where any limitations are imposed [i.e. door locks immobilised, issue of keys] Care plans must contain appropriate documentation in respect of this. You must make appropriate arrangements to ensure that all staff personal records are available for inspection at all times as required by Regulation 19, Schedules 2 and 4. Urgent Action by 28/04/08 You must take appropriate and Immediate action to ensure that staff are not employed to work at the home without the necessary recruitment checks as required by Regulation 19 of the Care home Regulations 2001 Schedules 2 and 4. Timescale for action 28/06/08 2 YA23 YA34 28/04/08 3 YA23 YA34 17,19 22/04/08 4 YA23 13[6] You must inform us within 24 hours by 1.45pm 22/4/08 of what action you have taken to address this. Obtain the Nottinghamshire 28/05/08 Safeguarding Protocols and apply these within the homes own policies for safeguarding and DS0000071237.V362834.R01.S.doc Version 5.2 Page 29 The Martins 5 YA23 YA37 37 change terminology for staff training. [i.e. from term POVA] You must ensure that the Commission for Social care Inspection is notified of any events which affect the Health and well being of individuals residing in the home as required by Regulation 37 21/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 Refer to Standard RCN RCN YA6 YA17 YA17 YA19 YA20 YA24 YA30 YA24 Good Practice Recommendations Ensure there is evidence that people living in the home/and /or their representatives have been issued with their own copy of the service user guide. Include in the Service use Guide information about how to access inspection reports. Where individuals are not able to sign agreement of their care plans ensure the section provided as to the reason why not is completed. Provide at least two options on the menu for people to choose from and provide pictorial aids for this process. Keep a record of options chosen. Look particularly at the presentation of soft diets to make them more appetising and that the individual is aware of food content before eating. Include Chiropody care in the healthcare record sheets. Monitor and record that medication is being stored at the safe recommended temperature. Address the issue of smoke emanation odours from the smoking area into the main lounge. Review the situation of the dining room being locked and ensure that risk assessments are in place should access be deemed to be unsafe for individuals to have access without staff. Provide lockable facilities in all bedrooms unless appropriate documentation is in place for an individual. Address the cleaning issues identified in the report. Ensure all staff are issued with a copy of the General DS0000071237.V362834.R01.S.doc Version 5.2 Page 30 10 11 12 YA26 YA30 YA34 The Martins 13 14 YA41 YA42 YA42 Social Care Council Code of Conduct. Ensure the fire risk assessment and electrical circuit certificate are available for inspection. Where water outlet temperatures are noted to be above 43 degrees in service users rooms or communal areas, ensure action is taken to remedy this and record a retest. The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Martins DS0000071237.V362834.R01.S.doc Version 5.2 Page 32 - 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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