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Inspection on 14/07/09 for The Mendips

Also see our care home review for The Mendips for more information

This inspection was carried out on 14th July 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The individuals accommodated spoke to the ‘expert by experience’ and positive comments about the home were made. People at the home said that activities were provided, their visitors were welcome and they new who to approach with complaints. Comments from staff about training confirm that the needs of the people accommodated are met by skilled staff. Regular individual’s supervision and handovers ensure that people at the home benefit from a consistent service.The MendipsDS0000026568.V376948.R01.S.docVersion 5.2

What has improved since the last inspection?

Since the last inspection the service provider has taken significant steps to develop a personalised approach to meeting needs. This will ensure that people at the home have input into the way their care is to be delivered. The service provider continues to adapt the property so that it fits the needs of the people at the home. The downstairs disabled toilet and shower will ensure that people with mobility impairments can maintain their independence.

What the care home could do better:

There are a number of requirements outstanding from the last inspection. These requirements relate to risk assessments, care planning, recruitment and protocols. Risk assessments for people with mental health care need must include the triggers, signs and symptoms of a deteriorating mental health. For people with aggressive and violent behaviours, management plans must include the triggers and safeguarding procedures that protect people from abuse. For a more personalised approach to meeting needs, the individual’s likes and communication needs must be incorporated into the care action plans. This will confirm that people have input into the way their care is delivered and guide staff on the way people make decisions. Medications protocols must be devised for people that have ‘when required’ medications. This will ensure that staff consistently administer medications. Home’s application forms must seek full employment history from candidates wishing to work at the home. Robust recruitment procedures will ensure that the people employed to work at the home are suitable to work with vulnerable adults.The MendipsDS0000026568.V376948.R01.S.docVersion 5.2Fire risk assessments must be further developed to include the fire systems checks and practices that must be carried out to ensure people live and work in a safe environment.

Key inspection report CARE HOME ADULTS 18-65 The Mendips 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL Lead Inspector Sandra Jones Key Unannounced Inspection 14th & 15th July 2009 09:00 The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mendips Address 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL 0117 9518548 0117 9518548 s_ghamy@hotmail.com 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.V376948.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 9 persons with mental disorder aged 30 years and over 23rd July 2008 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 fees range from £334.00 - £533.54 per week. Items not included in the fee include dry cleaning chiropody, clothing and hairdressing. Currently prospective residents are given this information verbally. The Mendips DS0000026568.V376948.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. This key inspection was conducted unannounced over two days in July 2009 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, this information was used to plan the inspection visit. An ‘expert by experience’ was used at this inspection, it is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service There are eight individuals living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions. What the service does well: The individuals accommodated spoke to the ‘expert by experience’ and positive comments about the home were made. People at the home said that activities were provided, their visitors were welcome and they new who to approach with complaints. Comments from staff about training confirm that the needs of the people accommodated are met by skilled staff. Regular individual’s supervision and handovers ensure that people at the home benefit from a consistent service. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There are a number of requirements outstanding from the last inspection. These requirements relate to risk assessments, care planning, recruitment and protocols. Risk assessments for people with mental health care need must include the triggers, signs and symptoms of a deteriorating mental health. For people with aggressive and violent behaviours, management plans must include the triggers and safeguarding procedures that protect people from abuse. For a more personalised approach to meeting needs, the individual’s likes and communication needs must be incorporated into the care action plans. This will confirm that people have input into the way their care is delivered and guide staff on the way people make decisions. Medications protocols must be devised for people that have ‘when required’ medications. This will ensure that staff consistently administer medications. Home’s application forms must seek full employment history from candidates wishing to work at the home. Robust recruitment procedures will ensure that the people employed to work at the home are suitable to work with vulnerable adults. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 7 Fire risk assessments must be further developed to include the fire systems checks and practices that must be carried out to ensure people live and work in a safe environment. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Mendips DS0000026568.V376948.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 The Mendips DS0000026568.V376948.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (1) & (2) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Statement of Purpose and Service User Guide provides sufficient information for people wishing to live at the home to make decisions about moving there. The admission process in place endeavours only to admit those individuals whose needs they can meet. The assessments conducted to establish that the staff can meet the needs of the people wishing to live at the home must be listed in the admission procedure. EVIDENCE: The prepared Statement of Purpose and Service User Guide inform people wishing to live at the home about the way their care will be delivered. It states that the aim of the home is to provide professional services for people with mental health needs, where people are respected as individuals. While the Statement of Purpose is up to date, the language used needs to be reviewed so that the information reflects current use of terminology. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 10 The way the service provider ensures that the staff have the skills to meet the needs of the people wishing to live at the home is explained through the admission procedure. The criteria for admission are specified and to determine compatibility, introductory visits are encouraged and trial periods offered. The assessments that will ensure that the home fulfils its commitment about the criteria purported, is not included in the admission procedure. The assessment that ensures that people wishing to live at the home meet the criteria for admission must be appended onto the admission procedure The eight people accommodated have lived at the home for a significant period to time. The Mendips DS0000026568.V376948.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7) & (9) People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans show that a personalised approach to meeting needs is used. For staff to move towards a more a personalised and consistent approach individual’s likes and communication needs must be incorporated into the action plans. EVIDENCE: Since the last inspection, the manager has further developed the home’s care planning system. The individual’s daily routines are recorded and there is evidence that consideration has been given to including the individual’s likes, dislikes and preferred routines into care plans. The individual’s spiritual and The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 12 dietary needs must be included within the care plans to further evidence personalised care. Care plans are signed by the person to show their agreement with the action plans, which are reviewed by the staff and the person. Minutes of the reviews are brief and do not show how the action plan can be ongoing because there is little information about the progress made with the action plan. Care planning was discussed with the staff at the home. We were told that the service provider formulates care plans with input from the staff and they attend care planning review meetings. Members of staff will then discuss the care plan with the person and once agreements about the action plans are reached they are signed by the individual to evidence agreement. Another member of staff that was recently employed said that care plans are accessible and at present the expectation is that care plans are read so that the individuals at the home receive personalised care. The service provider has attended MCA and DOLS training, the individual’s capacity to make decisions was assessed. Through the care plans the manager must then show the way people with communications needs make decisions. We were told that physical choices are given, family interpret complex decisions or translators are used. There is little evidence in the care plan that these methods are used, care plans must be more detailed to evidence that there is a clear procedure for supporting people to make decisions. The Mendips DS0000026568.V376948.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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: (12), (13), (15), (16) & (17) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are opportunities for people to experience a range of activities and are served a varied diet. EVIDENCE: An ‘expert by experience’ was used at this inspection, it is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. This individual was asked to seek information about activities, meals and household chores from the people living at the home. ‘The individuals seem to be quite happy in the home, and I could find no major problem for them. They also seemed to get on well with the member of staff, The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 14 who was present during the conversations’, was the ‘expert by experience’ conclusion of the home. The following questions were asked and their responses are included: 1. People were asked how they kept themselves occupied during the day. Individuals told us that they go to the pub, watch TV, read, talk to staff, listen to CD/radio were some of the activities that were undertaken. One person with spiritual needs usually meets with other people of the same faith. 2. What opportunities are available for education, occupation, and leisure? People did not express an interest in education and one person said that they were in voluntarily employed. 3. Who discusses the activities with them?’ Staff discuss activities which include e.g. board games, going into town, taking holidays. Staff accompany some individuals outside the home. 4. Are staff available to help access activities? There is always enough staff to help access activities. 5. Are they accompanied by staff on activities? People confirmed that when they are participating in activities staff always accompanies them. 6. Is there enough to do, and are they encouraged to be part of the community? Only some people wanted to go out into the outside community and they said that they had enough to do. 7. Is there an expectation that they participate in household chores, and what happens if they dont do them? People are not expected to do chores but some will vacuum their bedrooms for example. 8. Are there set bed times, and times to rise? There are no set bed times, or times to rise. Breakfast is served between 8a.m. and 9a.m. 9. How are menus done, can they make suggestions and are they allowed in the kitchen? The staff devise menus; people at the home can make suggestions which are sometimes used. There are no restrictions into the kitchen but there are restrictions on using the cooker. They can use e.g. the toaster and microwave. There is plenty to eat and sometimes there are seconds. 10. Do they have visitors? Some people have visitors, and these visitors are always welcome. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 15 Members of staff on duty were consulted about the opportunities available for occupation, education and activities. The staff told us that discussions about education and occupation take place but people at the home are reluctant to participate. We asked about visitors to the home and staff said that relatives, care coordinators, relatives and friends are welcome, which can occur in bedrooms for additional privacy. Staff’s feedback about the way people are respected as individuals was sought. They gave examples that show that the rights of people are respected, seeking permission before undertaking tasks, knocking and waiting for an invitation to enter bedrooms and keys to bedrooms are indication people are cared for in a dignified manner an in privacy. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (18), (19) & (20) People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems do not always follow good practice for ‘when required’ medications. EVIDENCE: People at the home are generally independent with their own personal care. Care plans and staff’s comments confirm that people at the home are mainly prompted. Care records in place contain documentation that show that people at the home have access to social and health care professionals. People at the home have routine dental and optician check-ups; visit the GP and go on hospital appointments. With the exception of two, the people at the home have a carecoordinator appointed. Individuals Care Programme Approach (ICPA) The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 17 meetings are convened annually through the Avon and Wiltshire Partnership Mental Health Services (AWP). Members of staff were asked to comment on the healthcare arrangements for people at the home. We were told that staff accompany people on healthcare visits, communication books and handovers are used to maintain staff informed on medical advice given. Medications are administered from the original packages and staff sign the records to show the medications were administered. During the review of the medication system it was noted that the staff administer ‘when required’ medications. Medication protocols for ‘when required’ medications are not currently in place and must be devised so that staff can consistently administer these medicines. A record of medications no longer required is maintained which the pharmacist signs to indicate receipt of the medication for disposal. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (22) & (23) People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. Management plans must include more detail about the actions needed to divert and diffuse behaviours that challenge EVIDENCE: The Complaints procedure is included in the Service User Guide and Statement of Purpose, which say that it’s the aim of the home to resolve complaints informally. The procedure confirms that complainants will be told of the actions needed to resolve complaints and states the names of the agencies including CQC that can be contacted for complaints that are not satisfactorily resolved. The Complaints book is kept in the dining room for people to record their complaint and there were no recorded complaints since the last inspection. It was stated that generally only the more formal complaints are recorded, otherwise complaints are resolved as they arise. The service provider said that they are reassured that people know who to approach with complaints. We were told that people are regularly asked if they have complaints and are directed to the complaints book for complaints. The service provider was consulted about the steps in place to ensure that people at the home are safeguarded from abuse. The Safeguarding policy in The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 19 place defines the factors of abuse and the actions to be taken for reporting alleged abuse. The Whistleblowing policy was not available at the home during the inspection. The purpose of the Whistleblowing policy is to reassure staff that if they will be protected from reprisals if they report poor practice, this also means that they are implications if they then witness poor practice and do not report it. For the service provider to fully evidence a commitment to safeguarding people from abuse, the Whistleblowing policy must be available at the home. The staff on duty were asked about the way people at the home are supported to make complaints. We were told that when individuals approach staff with complaints the issues are discussed with them so they can be informally resolved. It was also stated that where complaints cannot be resolved informally they are passed onto the service providers. Staff’s responsibility towards protecting people from abuse was also discussed with staff. It is clear from their comments that they know the factors of abuse and the procedure for reporting abuse. Risk assessments are in place for any activity that may involve an element of risk including behaviours that challenge the service. Management plans are then devised and, from the risk identified, known triggers are listed. For people that may present aggressive and violent behaviours or abuse drugs, risk assessments are in place. However, these risk assessments must include more details about the actions that staff must take. The options and triggers must be clearly stated to show that the actions are consistent with the level of risk. This will limit the staff interpretation of the actions needed to diffuse and divert behaviours that challenge providing a more consistent approach. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people at the home benefit from living in a comfortable and clean environment EVIDENCE: Two terraced properties were originally converted to offer accommodation to nine adults with mental health care needs. The property of the service providers adjoins and can be accessed through the care home. It has the appearance of a domestic dwelling, which blends well with its immediate environment and within walking distance of shops, library, amenities and bus routes. The accommodation is arranged over two floors with shared space on the ground floor and bedrooms on both floors. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 21 Shared space at the home comprises of a lounge and dining room. In the lounge and dining room there is sufficient seating for the individuals at the home to sit together as a group. There is a pay phone available in the corridor for people to make personal calls. Bedrooms are single and lockable, with a combination of the home’s furniture and individual’s personal belongings. The tour of the premises confirmed that the service provider takes steps to maintain the property to a good standard. The service provider told us that the lounge furniture was to be replaced. . The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (34), (35) & (36) People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are supported by competent and skilled staff whose performance is monitored and have opportunities for personal development. The service provider has failed to provide robust recruitment procedures, which ensure staff employed, are suitable to work with vulnerable adults. EVIDENCE: There are two staff currently employed and with the service providers working ‘hand on’ make up the staffing levels. At the previous inspection, a requirement to seek through the application form, full employment history of potential staff was required. This requirement is outstanding and the service provider must review the application form to comply with legislation. The service provider must update the application form to seek full employment history. Written references were The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 23 in place for the staff employed. However, not all references were validated; the service provider must ensure the authenticity of references sought. A more robust recruitment process will ensure that every effort is made to employ people that are suitable to work with vulnerable adults. Since the last inspection existing staff have attended refresher statutory and specific training that ensures the changing needs of the people at the home are met. Statutory training in First Aid, Safeguarding training and vocational qualifications were undertaken by one member of staff. Mental Health, Mental Capacity Act and Parkinson Awareness training was also attended in 2008. The most recently employed member of staff has undertaken the Skills for Care induction programme and the home’s induction. Staff supervision occurs 8 weekly with the service provider where performance and personal development is discussed. Staff’s feedback was sought about training and supervision. Staff said that training is encouraged and confirmed the training provided since the last inspection. Regarding supervision staff confirmed the frequency and said menus; performance, activities and improvements are usually discussed at these meetings. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (37), (39) & (42) People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The individuals at the home can be reassured that the home is subject to ongoing monitoring and there is a consistent approach to meeting needs. The service provider must take steps to ensure people live and work in a safe environment. EVIDENCE: The service provider is competent and qualified to operate the care home confirmed through the nursing and vocational qualification. A discussion took The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 25 place with the service provider about the future plans of the home. We were told that that there is a refurbishment programme to maintain a homely environment for the people living there and more training is to be provided. Ensuring that staff can meet the changing needs of the individuals accommodated. The staff at the home were asked to make comments about the leadership style used by the service provider. We were told that the service provider is approachable, they are prompt to take action and they are informed about policy changes and the changing needs of the people at the home. There is a Quality Assurance system in operation and a variety of methods are used to seek feedback from people at the home, which include surveys and public forums. Questionnaires based on the standards of care are used annually to seek the views of the people at the home and residents meetings are open forums for feedback about the running of the home. The service provider told us that feedback received is used to make changes to improve the quality of the individuals experience at the home. Facilities for the safekeeping of cash and valuables exist at the home and at the time of the inspection three people had cash in safekeeping. The records examined correspond with the balances held; however, more detailed information is needed about the cash paid in for safekeeping. The service provider ensures that associated legislation is complied; competent contractors are used to annually check portable electrical equipment and boilers so that a safe environment for people living and working at the home can be maintained. Fire risk assessments are undertaken to assess the potential of fire in the home. Following a recent visit from the Avon Fire Rescue, it was recommended that the service provider improve the risk assessments by describing the steps taken to prevent fire, which include practices and checks. The manager must ensure that fire risk assessments assess the potential of an outbreak of fire in the home and list practices and checks that must be conducted to prevent an outbreak of fire. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 26 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 3 2 3 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 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Version 5.2 Page 27 The Mendips DS0000026568.V376948.R01.S.doc 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 YA9 Regulation 13 (4) (b) Requirement Risk assessments that include a) for people with mental health care need must include the triggers, signs and symptoms of a deteriorating mental health. b) For people with aggressive and violent behaviours risk assessments must include the triggers and safeguarding procedures that protect people from abuse. For a more personalised approach to meeting needs, the individual’s likes and communication needs must be incorporated into the care action plans. Medication protocols must be devised for people that have ‘when required’ medications. This will ensure the medications are consistently administered. Home’s application forms must seek full employment history from candidates wishing to work at the home. Timescale for action 30/10/09 2. YA6 12 (3) 30/10/09 3. YA20 12 (2) 30/08/09 4. YA34 7,9 & 19 Sch.2.6 30/09/09 The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 28 5. YA42 23(4) Fire risk assessments must be further developed to include the fire systems checks and practices that must be carried out to ensure people live and work in a safe environment. 30/08/09 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 YA1 Good Practice Recommendations 1 The service provider should append onto the admission procedure the assessment that will be conducted to ensure the staff have the skills to meet the needs of the people wishing to live at the home. The Mendips DS0000026568.V376948.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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