Inspection on 14/02/06 for The Mendips

This inspection was carried out on 14th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mendips 14/07/09

The Mendips 23/07/08

The Mendips 12/07/07

The Mendips 12/07/06

The Mendips 29/09/05

The Mendips 16/02/05

The Mendips 01/07/04

The Mendips 10/03/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 The Mendips 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL Lead Inspector Sandra Jones Unannounced Inspection 14th February 2006 09:30 The Mendips DS0000026568.V283475.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 The Mendips DS0000026568.V283475.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. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Mendips Address 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL 0117 9518548 0117 9518548 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) Mr Mamode Raschid Ghamy Mrs Bibi Ghamy & Mr M R Ghamy Mrs Bibi Ghamy & Mr M R Ghamy Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (9) The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 9 persons with mental disorder aged 30 years and over 29th September 2005 Date of last inspection Brief Description of the Service: The Mendips is operated by Mr and Mrs Ghamy, it is a registered care home for nine adults with mental health care needs, aged 30 years and over. The home is situated close to the Fishponds Road and is within walking distance of shops, library, places of worship and other amenities and bus routes. The property has the appearance of a domestic dwelling and blends well with its local environment. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second unannounced inspection for the year 2005/2006. To make judgements on the home, both reports must be read in conjunction. There were no additional visits to monitor practices since the last inspection. During the inspection residents feedback was sought on the standards of care and staff on duty were consulted on the conduct of the home. The records examined were used to confirm the established practices and a tour of the premises was conducted. What the service does well: What has improved since the last inspection? Since the last inspection, the service provider has adopted a person centred approach to meeting residents needs. Further developing the approach will ensure that residents can express views, aspirations and goals and will enable the service provider to develop an action plan that incorporates the individuals The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 6 likes, dislikes and preferred routines. During the inspection the service provider was arranging a holiday for one resident. 1:1 time with residents has taken place since the last inspection, which residents have clearly enjoyed. The service provider has taken steps to achieve an adequate standard of décor. 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. The Mendips DS0000026568.V283475.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 The Mendips DS0000026568.V283475.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 examined at this inspection. EVIDENCE: The Mendips DS0000026568.V283475.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 Person centred approach to meeting residents needs which has been started and must be developed so that it creates a framework that enables the resident to make choices, express views and preferences. Risk assessments and reactive strategies must be completed for any activity that may involve an element of risk and to develop positive behaviours. Including manual handling. EVIDENCE: Since the last inspection, steps have been taken to developing care plans into a person centred approach to meeting needs. Care plans that list the prescribed medications and identified risk are in place. Assessed needs are clearly defined and the interventions needed to meet the identified need. In order to develop person centred care, the action plans must specify the individuals like, dislikes and preferred routines. The key elements of rights, choice, inclusion and independence must be incorporated to create a framework that enables the resident to make choices, express views and preferences. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 10 While the residents accommodated can communicate verbally, English is not the first language for one resident and another will always respond in a positive manner. Care plans must detail the communication needs of these two individuals. Once a person centred approach is adopted, care will describe the individuals abilities to make decisions. Activities that may involve an element of risk are identified and focus on smoking, mobility and health care. Within the risk assessment, the actions to be taken to minimise the level of risk must be detailed. It is evident from the case files that two residents exhibit aggressive and violent behaviour. Reactive strategies that detail the triggers must be developed which include the actions to diffuse and divert potential aggressive and violent behaviours. For residents that are subject to section under the Mental Health Act, risk assessments must specify the conditions and the consequences for breaches of the conditions. The Mendips DS0000026568.V283475.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): 12,13,15 & 17 The service provider must consult residents on their goals in terms of education and occupation during reviews and assessments. Members of staff support residents that require assistance outside the home ensuring their access to community facilities. Visitors to the home are made welcome by the staff strengthening links with family and friends. Residents have a varied diet that is wholesome. EVIDENCE: Four residents currently attend structured day care centres and one person pursues their religious believes each day. Three residents have no structured community day care provision. During reviews and assessments the service provider must discuss with residents their goals in terms of education and occupation. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 12 Four residents can leave the home independently and staff accompany four residents to assist with crossing the road. It was understood from the service provider that the staff accompany residents to visit shops, theatres and restaurants. Additional comments were made by the service provider regarding outings to be organised. Residents consulted confirmed that 1:1 with the service provider are taking place and visits to the cinema were recently organised. Risk assessments must be completed for residents that require assistance with moving and handling to establish a plan of action. Visitors to the home are welcome. Residents confirmed that whenever their friends and family visit, the staff greet their visitors in a positive manner. It was reported that visits can take place in the shared space or in their bedrooms for additional privacy. The record of food provided at the home indicates that three meals are served each day. Residents confirmed that the meals prepared are suitable and rarely are alternatives requested. The range of frozen, fresh and tinned foods accommodate the menu of food served at the home. A record of fridge, freezer and cooked temperatures is maintained and complies with Food Safety Act. The Mendips DS0000026568.V283475.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 Safe practices of administration, ordering and disposal of medications exist at the home. EVIDENCE: Medications administered by the staff are through standard bottles. The medication administration records indicate that staff sign the records immediately after administration. The medications held in the secure cabinet were checked against the records of administration and safe handling of medicines was demonstrated. A record of medications no longer required at home is maintained and countersigned by the pharmacist, to evidence receipt for disposal. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 14 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 & 23 Residents confirmed that their views are sought and expressed their confidence with the actions taken to resolve their complaints. The home’s abuse policy must follow “No Secrets” guidelines to safeguard residents. EVIDENCE: Residents reported that the service provider would be approached with complaints. Their comments indicated that complaints raised would be taken seriously by the service provider and acted upon. The home’s Abuse policy explains the types of abuse, the possible signs, with a checklist of actions to be followed if abuse is suspected. In order to follow current good practice guidelines, the checklist must be formulated in line with the “No Secrets” policy. Other policies that that safeguard residents from abuse are listed within the policy. The service provider and one member of staff have completed POVA training and two of the most recent employees will be attending the training. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 15 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, 30 The property is maintained to an adequate standard, repairs are undertaken as they occur. To reduce the risk of infection the seal around the basin must be replaced. EVIDENCE: Since the last inspection, the service provider has taken steps to achieve an adequate standard of décor. The tiles in the downstairs toilet were repaired and during the inspection property maintenance was taking place. A recent flood from the upstairs toilet has damaged the ceiling in a downstairs room. At the time of the inspection, a contractor was repairing the damage. The laundry room is sited away from the kitchen. The floors and walls are painted making the surfaces easily washable. The washing machine and tumble dryer are domestic in scale. There is hand-washing facilities in the laundry, to maintain a hygienic environment the sink must be sealed to prevent cross infection. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 16 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): 34 & 35 The recruitment procedure in place endeavours to employ members of staff that are suitable to work with vulnerable adults. The most recent employees must complete POVA and mental health training to ensure residents needs are met. EVIDENCE: Two members of staff were employed at the home since the last inspection. Their personnel files contain completed application forms, two references and other documentation that establishes the person’s suitability to work with vulnerable adults. It was understood that CRB’s have been requested in respect of these staff. One member of staff has completed POVA and Mental Health Care training since the last inspection. One of the new employees is a qualified nurse and the other has undertaken Basic Health training and NVQ level 2. Mental Health and POVA training must be undertaken by these staff to meet the needs of the residents needs. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 17 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): 39 & 41 The records examined are well managed and up to date which contribute to the effective running of the home. The service provider ensures that members of staff are aware of the expectations of the role, providing a positive atmosphere at the home. EVIDENCE: A member of staff on duty was consulted on the conduct of the home. The member of staff reported that employment at the home was recent, in the last two weeks. The member of staff confirmed that job descriptions had been provided and ensured clarity with the expectations of the job. This individual described the tasks and activities undertaken with residents since employment. It is evident from the rota in place that the service provider and one member of staff are on duty throughout the day. As the service provider’s property is adjoined to the home, they undertake sleeping-in cover. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 18 Facilities exist at the home for the safekeeping of cash and valuables. Currently two residents have cash in safekeeping and the records were up to date and consistent with the balances held. Individual schedules are in place for Local Authority placements, listing the weekly charges and the source that contribute towards the fees. The records that relate to fire safety practices and checks were examined. The records indicate that practices and checks are conducted at the stipulated frequencies. The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 19 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 3 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 x 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X x 3 x x x 3 x 3 x x The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1) Sch. 1 Requirement a) The status for accommodation under the Mental Health Act must be listed in the Statement of Purpose. (Previously required 1/7/04, 16/2/05 &29/09/05) A person centered approach to meeting residents needs must be incorporated into the care plans. a) Risk assessments must be completed for activities that may involve an element of risk. b) Manual handling assessments must be completed for residents that require assistance outside the home c) Reactive strategies must be developed for residents that may exhibit aggressive and violent behaviour. Residents must be consulted on their goals for education and occupation to develop and action plan to meet these goals. Members of staff must attend Mental Health training. The seal around the hand wash DS0000026568.V283475.R01.S.doc Timescale for action 30/03/06 2. YA6 15 30/06/06 3. YA9 13(4)(b) 30/06/06 4. YA12 12(1)(b) 30/06/06 5. 6. YA32 YA30 18(a) 23(2)(b) 31/05/06 30/04/06 Page 21 The Mendips Version 5.1 5. YA32 13(6) basin in the laundry must be replaced a) Members of staff must attend POVA training. b) in-house policies and procedures must follow “No Secrets” guidelines 31/05/06 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 The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 The Mendips DS0000026568.V283475.R01.S.doc Version 5.1 Page 23 - 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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