CARE HOME ADULTS 18-65
The Mendips 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL Lead Inspector
Sandra Jones Unannounced 29 September 2005 9:30
th 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 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 Stationary 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 D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 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 Care Home Only 9 Category(ies) of MD Mental Disorder,9 registration, with number MD(E) Mental Disorder -over 65, 9 of places The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: May accommodate up to 9 persons with mental disorder aged 30 years and over Date of last inspection 16-Feb-2005 Brief Description of the Service: The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis over one day in September. While there were no additional visits since the last inspection a monitoring visit will take place to check fire records. The one member of staff and one resident at the home were consulted on the standards of care. The records and tour of the premises were other sources used to evidence the findings of the inspection. What the service does well: What has improved since the last inspection? What they could do better:
Outstanding requirements that relate to the environment and fire training must be actioned to prevent enforcement action for non-compliance. Members of staff must attend fire training to ensure residents and staff’s safety in the event of a fire. Care plans must be further developed to demonstrate that the home can meet residents needs. Outstanding requirements for must be actioned as non compliance
The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 6 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 D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 standard(s) 1 The Statement of Purpose requires further development to enable potential residents, their representatives and placing agencies to make decisions about the home. EVIDENCE: Outstanding requirements that relates to adding information to the Statement of Purpose were checked. The staffing levels and intended training is included in the Statement of Purpose. The intended induction to be followed, statutory training and vocational qualifications achieved by the staff is detailed. While the criteria for admission is described, the status for accommodation at the home under the Mental Health Act must be listed. The room sizes were added to the Statement of Purpose as previously required, which indicate that all rooms meet NMS of 10sq.m. The CSCI address and telephone number is included within the Service User Guide. The Service User Guide must be appended onto the Statement of Purpose or the CSCI address must be included to the Complaints procedure appended onto the Statement of Purpose. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 standard(s) 6&10 Care plans must be further developed to guide the staff to consistently meet the needs of the residents. The Confidentiality policy must include the arrangements for maintaining residents documentation and records securely. EVIDENCE: Home’s care plans, which list the assessed needs, and action plan were developed from review meetings. The action plans must be clearer in terms of the guiding the staff to meet the person’s needs. Triggers of a deteriorating mental health must be incorporated into the care plans, along with the staff’s approach. For residents subject to section under the Mental Health Act, care plans must detail the conditions and the actions for breeches of these sections. Reports of significant evidenced that some residents at times exhibit aggressive and violent behaviours. Strategies for diffusing and diverting these behaviours must be devised. The Confidentiality policy describes the expectations of the staff towards sharing information and access with the implications for breeches of
The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 10 confidentiality. The arrangements for maintaining documentation and records about the residents must be detailed. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 standard(s) 16 House rules about household chores and routines are designed to promote independence. EVIDENCE: The resident at the home during the inspection was consulted on the rules and routines of the home. It was reported that bedrooms are single and keys are provided to ensure privacy. There is an expectation that residents participate in household chores, which depends on the individuals level of ability. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 12 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 standard(s) 18,19&20 A person centred approach must be used to develop action plans for personal care tasks. Enabling residents to have meaningful involvement in decisionmaking about their delivery of care. Residents healthcare needs are assessed. To recognise residents health care needs, care plans must incorporate triggers of a deteriorating mental health. For safe practices of medication, medication processes must meaningful. EVIDENCE: The residents currently accommodated do not require assistance with moving and handling. Care plans describe the assessed needs of the residents including their personal care. From the care plans the it is evident that the current residents are prompted and supervised with personal care. A more person centred approach with meeting the needs must be developed. Two residents currently have spiritual needs. One person is a Jehovah’s Witness and canvasses daily with congregation members. The other is Bahai and relatives support the person to fulfil their spiritual needs. The current residents have input from a psychiatrist and have an annual review, which focus on all aspects of their wellbeing.
The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 13 Residents visit NHS Community facilities. The service provider stated that residents can visit the optician, dentist and chiropodist independently or accompanied by the staff. The support needed by residents to visit the chiropodist, dentist and optician must be detailed in the care plan. Documentation kept at the home evidenced that residents can access specialist support. Medications are administered from standard bottles by the staff at the home. From the records of administration, it is evident that staff sign the records immediately after administration. However, the process is not meaningful. It is clear that the documentation is not read before it is signed. Drug profiles that describe the purpose of the medication, its side effects and compatibility with homely remedies must be developed. Which must form the basis for competence training for the staff that administer medications. A record of medications no longer required is kept at the home, which the pharmacists countersigns to indicate receipt of the medication for disposal. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 standard(s) 22 Residents expressed their confidence with the service provider seeking their views and acting upon them. EVIDENCE: There were no complaints received at the home or CSCI for investigation, since the last inspection. Residents consulted expressed their confidence with the staff acting upon the concerns raised. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 standard(s) 24 The tiles in the downstairs toilet and the ceiling in the upstairs bathroom require attention to ensure the environment is comfortable. EVIDENCE: Two terraced properties were converted to provide accommodation and personal care for up to nine adults with mental health care needs. The property has the appearance of a domestic dwelling, which blends with its local residential environment. It is arranged over two floors with shared space on the ground floor and bedrooms on both floors. Access into the home is on a gradient with small steps into the home and stairs to the first floor. The property is decorated to an adequate standard and previous requirements were partially met. The tiles in the ground floor toilet and the ceiling in the upstairs bathroom are previous requirements that remain outstanding from the last inspection. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34&35 Applicants must provide a statement about their physical and mental fitness during the recruitment process. To further progress a thorough recruitment procedure, referees must asked to validate the request for reference forms. The induction programme for new staff must meet good practice guidelines. Staff must attend statutory and mental health training to equip staff to meet the changing needs of the residents. EVIDENCE: One member of staff was employed at the home since the last inspection. Documentation in place establishes the suitability of the person to work with vulnerable adults. Application forms must seek information from the applicant on their physical and mental fitness to promote a robust recruitment process. For request for references formats, validation from the referee must be requested. For example, compliment slips, organisational stamp. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 17 While the service provider has made arrangements for external mental health and statutory training, the induction programme must be clearer. An initial familiarisation for new staff is defined. The induction programme must be devised within good practice guidelines. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 The service provider is approachable which creates an open culture at the home. Fire training must be provided and records of fire drills must be accurate. EVIDENCE: Feedback on standards of care was sought from the member of staff on duty. It was reported that the service provider is approachable and provides the information necessary to complete tasks. Supplementary comments about the style of management included clarity about the expectations of the job. The equipment and access to information, available to do the job are added sources for positive culture. The heating contractor has visited and raised a certificate to indicate that the system is safe.
The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 19 The records of fire safety policies, procedures, checks and practices were examined. From the records, the checks are conducted at the stipulated frequencies. In terms of the fire training, staff must attend fire training at six monthly intervals. The names of the members of staff that attended fire drills must be listed in the log book. Fire training is a requirement that remains outstanding from the last inspection. The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23
ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x x 2
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 1 x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x 3 x Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
The Mendips Score 2 2 1 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 1 x D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 21 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 Standard 1 Regulation Requirement Timescale for action 30.2.06 2. Standard 6 3. Standard 10 Standard 20 Standard 24 4. 5. 6. Standard 42 Regulation a) The status for accommodation 4(1) Sch. under the Mental Health ACt 1 must be listed in the Statement of Purpose. b) Address and telephone number of the CSCI must be included in the Complaints procedure. (Previously required 1/7/04, 16/2/05) Regulation Care plans must be further 15 developed to guide the staff. b)Potential triggers of a deteriorating mental health must be included in the care plans, c)A person centered approach to meeting residents needs must be incorporated into the care plans Regulation The Confidentiality policy must 12(4) describe the arrangements for the safe storage of residents records and documentation. Regulation Medication records must be 13 (2) signed for medicines administered. Regulation The tiles in the ground floor 23 toilet msut be repaired, The ceiling in the upstairs bathroom must be repaired. (Previously required 16.2.05) Regulation a) The names of staff attending 17(2)Sch. fire drills must be listed in the
D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 30.2.06 30.12.05 30.10.09 30.1.06 30.12.05
Page 22 The Mendips 7. Standard 34 fire book (Previously required 16.2.05) b) Members of staff must attend fire training. Regulation a)Application forms must seek 19 information about the persons physical and mental fitness. b) Request for reference forms must request validation . 4.14 & 23.4 30.12.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Mendips D56_D05_26568_Mendips_241865_160805_Stage4.doc Version 1.40 Page 23 Commission for Social Care Inspection Bristol North Lo 300 Aztec West Almondsbury Bristol, BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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