Inspection on 04/04/07 for The Merchant`s House

This inspection was carried out on 4th April 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Merchant`s House 13/02/06

The Merchant`s House 18/08/05

The Merchant`s House 25/02/05

The Merchant`s House 09/11/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 The Merchant`s House The Merchant`s House 80 Prenton Road East Prenton Birkenhead Wirral CH42 7LH Lead Inspector Beate Roth Key Unannounced Inspection 4th April 2007 09:45 The Merchant`s House DS0000059613.V296641.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 Merchant`s House DS0000059613.V296641.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 Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Merchant`s House Address 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) The Merchant`s House 80 Prenton Road East Prenton Birkenhead Wirral CH42 7LH 0151 0151 Inclusive Lifestyles Mr Andrew Frankel Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To maintain the agreed staffing level of three staff at all times until further discussion with the CSCI 13th February 2006 Date of last inspection Brief Description of the Service: The Merchants House is registered to provide personal care for 6 adults with a learning disability. The Merchant’s House is a large detached property in the Prenton area on the Wirral. It is close to Birkenhead town centre and is a short walking distance to local shops and public transport. The accommodation in the home is specifically designed and equipped to meet the needs of the residents. There is a lift, hoists and walk in showers available. The accommodation provided is in single bedrooms with an en-suite facility. On the ground floor, there is a lounge and dining room and on the second floor there is a further lounge. There is an enclosed garden to the rear of the property. Limited parking is available in the grounds of the home and is available on the road outside the home. The home provides a vehicle to give residents the opportunity to go out individually or together. At the time of the inspection, the weekly cost for the service ranged from £2879.00 to £7,274.00. A statement of purpose, which describes the services offered at The Merchant’s House, is available for relatives and social and health professionals to refer to. A service user guide that is suited to the needs of the residents is in the process of being developed. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 8.5 hours and is based on a visit to the home, information received about the service since the last inspection and by questionnaires completed by the responsible individual, relatives and health and social care professionals. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the responsible individual and acting manager. A tour of the home was undertaken. The inspector spoke with staff and residents and made observations of staff delivering care to the residents. What the service does well: What has improved since the last inspection? Since the last inspection checks of the fire alarm and emergency lighting are occurring on a regular basis. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 6 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 Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 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 Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 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): 1, 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process does not fully ensure that the service is only offered to individuals whose needs can be met at the home. It was not possible to assess if the wellbeing of residents is supported by the contracts they have with the home, as this documentation was not available. EVIDENCE: At the last inspection it was reported that a lengthy pre-admission assessment of residents needs is carried out to ensure that the move to the Merchant’s House causes minimal disruption and anxiety to the new and existing residents. The assessment process allows for the religious, cultural, language and racial needs of residents to be assessed. Since the last inspection two new residents have come to live at the home and both have since left. The records of the assessment of one resident were seen. The records did not provide evidence that a comprehensive assessment was completed prior to their admission. The behaviour displayed by the resident was the main reason for their leaving the home but there was little information around the behaviour that can be displayed and how to manage this prior to the resident’s admission. The acting manager reported that the resident was admitted to the home on an emergency basis. The statement of purpose for The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 9 the home does not indicate that emergency admissions are accepted and a discussion with the acting manager and responsible individual indicated that this would not meet the needs of the current resident group. The statement of purpose is currently being revised. A copy is available to give to relatives and health and social care professionals. The statement of purpose provides a good overview of what the home offers, however, it needs to clearly indicate the service provided at the home. It is not clear that long term care is provided, a resident has been admitted for a respite period in the past and the policy and procedure regarding emergency admissions (if any) is not indicated. A service user guide is available however the current format is not suitable for the people for whom the home is intended. The service user guide and statement of purpose should outline how the needs of individuals from minority groups can be met within the service. Contracts between the home and the residents were not available at the home and so it was not possible to assess if residents have up to date written information around the fees payable and what this covers. The responsible individual said that the residents are provided with a contract and a copy is kept at another office base. A record of the care home’s charges to residents, including any extra amounts payable for additional services must be kept at the home. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to the service. Care planning reflects the assessed needs of residents, however, residents could be better supported by the information recorded in the behaviour management plans. EVIDENCE: The residents at Merchants House have a high level of staff support throughout the day. Detailed care plans and risk assessments have been developed to give guidance to staff on how to support residents to ensure their safety, care and health needs are met. Daily records are made in each resident’s file, which, show the wellbeing of the resident. The care plans contain information around goal setting but the steps to be taken to achieve these goals could be made clearer. Relatives who completed questionnaires made very positive comments about the care provided. Relatives reported that they are consulted about their relatives care and kept informed of important matters. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 11 The care plans generally provide clear guidance to staff around managing aggressive behaviour or self-harm. Staff are appropriately trained in the management of challenging behaviour. One behaviour management plan seen did not include the action staff are to take to respond to a resident when they are harming themselves or others. This information needs to be clearly documented for staff to refer to. Records showed that reviews of care plans take place on a regular basis. The views of parents, health and social care professionals inform the reviews but at present a formal review with all relevant individuals is not taking place. The responsible individual has identified this in a recent audit of the service and is in the process of addressing this and making the review cover a wider range of issues. The staff spoken with knew about the needs of the residents and appeared to have a very good friendly relationship with them. Residents appeared relaxed and content when with the staff. A resident spoken with said that they enjoyed living at the home and identified staff they enjoyed working with. The records showed and staff said that residents are assisted to make decisions about their lives in accordance with their abilities. Communication guidelines assist in this process. These guidelines need some further development. The manager and staff are working with a speech and language therapist around this. The acting manager is currently looking at different ways in which residents and their representatives would be able to increase their participation in the day-to-day running of the service. The service has various policies and procedures, which are accessible to residents and their representatives. Where necessary policies would be provided in large print. The service should consider providing some policies e.g. abuse policy in different formats to make it easier for residents to understand the contents of the policy. . The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 12 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, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in appropriate activities that provide opportunities for their social and personal development. Links with the local community are promoted. The daily routines support residents. Varied and well-balanced meals are provided in homely surroundings. EVIDENCE: Residents are encouraged to develop independent life skills such as preparing food, shopping and keeping their bedrooms clean. Programmes of suitable activities are in place to suit the residents’ choices and abilities. A daily diary report is completed for each resident, which, details what the resident has done each day. The responsible individual has recently identified that the activities programmes need to be reviewed to ensure they are fully reflecting the activities that residents currently like to do. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 13 A resident said “it’s great here, staff take us out a lot.” “I can choose what I do, I cook my own meals and do my shopping,” the staff “give me help when I need it.” Residents make use of community facilities such as local pubs, shops, leisure centres and restaurants. The home is located close to shops and other community resources. The home has its own transport, which enables community participation. A social worker said that the home provides a “socially rich” place to live. Staff said that the “residents take part in community life”. Staff support residents to maintain contact with their family and friends. Residents are able to choose where to see their visitors. However, on occasions this maybe restricted depending on the needs of other residents. As part of one of the residents’ package of care, staff accompany the resident to their family home for the weekend. Relatives said that the home “helps them to stay in touch”. Residents make choices about their daily lives such as what to do each day, what time and where to eat meals, whether to spend time in the communal areas of the home or their bedrooms. Residents have access to all parts of the home. Residents take part in household tasks such as cleaning and tidying in accordance with their abilities. Relatives and social workers said that the privacy of residents is maintained, that the service supports residents to live the life they choose and that the service responds to the different needs of individual people, in terms of their gender, ethnic and religious background, race, disability, faith and sexual orientation. Meals are provided that are balanced and offer choice and variety and reflect the cultural background of the residents. A record of residents likes and dislikes and dietary needs is available. Advice is obtained from a dietician if this is required. Residents are helped to eat their meals and there are support guidelines for staff to follow around this. Meals are eaten in the resident’s bedroom or in the dining room. The dining room provides a homely and pleasant area for residents to eat meals. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health needs of residents are well met, however, residents are not fully safeguarded by the home’s handling of medicines. EVIDENCE: There is clear information available for staff on residents’ personal care routines that indicate their preferences. Personal care takes place in the privacy of residents’ bedrooms. The records seen provide information on the morning and evening routines of each resident. Observations indicated that staff promote the dignity of residents and that they are supportive and caring towards them. Staff interviewed were very aware of the support needs of residents. Staff monitor all aspects of resident’s health and significant changes are referred to the resident’s GP. Procedures for managing specific health needs are available. Training is provided to staff around meeting specific health needs. Where residents require assistance with transferring an occupational therapist assesses the needs of the residents and suitable aids are obtained. Appropriate training is provided to staff in the use of the equipment. The staff The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 15 at the care home access support and advice from a speech therapist, psychologist, continence adviser and other specialist health professionals as necessary. A social worker reported that the residents’ health care needs are properly monitored and always attended to at the home. Relatives said that the needs of residents are well met. One said “ needs are well catered for and the atmosphere is relaxed and flexible.” GP’s who returned questionnaires said that they are satisfied with the overall care provided at the home and that any specialist advice is put into the residents plan of care. Staff who administer medication have all received training around the safe handling of medication. The home receives advice and guidance from the local pharmacy as necessary. The medication administration records and corresponding medication were inspected. One tablet was administered which was not recorded. At the last inspection of the service it was identified that medication was administered which was not recorded. A record had not been made of medication that leaves the home when residents visit relatives and any medication that is returned following these visits. A record must be made of all medication that leaves the home and is received at the home to ensure there is no mishandling. A discussion with the acting manager indicated that the procedure for administering medication does not safeguard residents. Medication is stored in a secure room in the basement of the home. Staff dispense medication into a medication pot in the medication room and then take this to each resident in turn wherever they may be in the building. The medication records are signed in the basement after each resident has been given their medication. In order to avoid mishandling of medication or medicines being incorrectly administered, medicines should be taken in a secure container to the resident together with the medication administration sheets. In order to further safeguard residents, a photograph of each resident should be attached to the medication administration record sheets. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The systems in place for managing complaints and adult protection matters ensure that the wellbeing of residents is safeguarded. EVIDENCE: Residents, relatives and any advocates have access to a suitable complaints procedure, which gives them a clear picture of how to raise a concern or complaint. There have been two complaints since the last inspection. In general records and a discussion with the responsible individual showed that the complaints had been appropriately managed. Some supporting records are held at the head office, which the responsible individual agreed to provide to CSCI. The staff spoken to, were aware of the content of the complaint procedure and how to respond to complaints. Relatives said that they know how to make a complaint and that “we always feel we can approach any of the staff with confidence knowing we will be dealt with kindly and appropriately.” A clear and detailed safeguarding adults procedure was available at the home. In addition training around recognising signs of abuse and the procedure to follow when reporting an incident of abuse is provided to staff. The staff spoken with had a clear understanding of the safeguarding adults procedure. Two referrals had been made to Wirral Social Services under the safeguarding adults procedure since the last inspection. In both cases, the referrals were not pursued by Wirral Social Services. The reason for this was not documented at the home and it is recommended that this information be The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 17 clearly recorded. One matter that was reported to adult protection had been looked into by management from the home. A discussion with the acting manager and responsible individual indicated that appropriate action had been taken. The records relating to this were not available. Records relating to a member of staff’s employment must be held at the home unless an agreement has been reached with CSCI. Records showed that the finances of residents are appropriately managed. Policies and procedures are in place regarding residents’ monies and a secure place is provided for the storage of residents’ monies/valuables. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 18 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, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The home is clean and well presented and provides a comfortable and pleasant environment for residents. EVIDENCE: The home is well maintained. Some areas of the home were showing some signs of wear and tear and steps had been taken to address this. Furnishings are of a good quality. There is a programme of decoration and replacement of furnishings, which ensures good standards are maintained. The communal areas can be used for a variety of purposes and all areas on the ground floor are accessible to all of the residents as there is a lift to assist wheelchair users over a few steps from the annexe to the dining room and the main lounge. The bedrooms seen were decorated to reflect residents’ tastes. Residents are encouraged to choose the wall decoration and to bring personal belongings into The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 19 the service. All bedrooms have an en-suite facility where there is a walk in shower and taps at wash hand basins are controlled by a sensor. A thermostatic valve is used to control the hot water temperatures at the shower and wash hand basin, which are tested regularly. Residents are provided with a key to their bedrooms once this is assessed as being safe. Policies and procedures are in place for the prevention of spread of infection and the laundry facilities are sited away from the food preparation area. Staff receive training in health and safety as part of their induction training. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Residents are safeguarded by the number of staff available and by the training staff have received. Residents would benefit further if 50 of staff had completed an NVQ in care or equivalent. The recruitment practices safeguard residents. EVIDENCE: Residents have a high level of support from staff in accordance with their needs. Records, observations and a discussion with staff indicated that there are enough staff to meet the needs of the current residents. Observation showed that staff are available for residents, knowledgeable about the needs of the residents and are committed to providing a high quality of care. Residents are supported by staff in the least intrusive way as possible within the constraints of the residents’ care plans and risk assessments. Staff commented that they feel supported by the management of the home. The staff said that the acting manager is available at all times and listens to the views of staff and residents, where possible, about the running of the home. Weekly team meetings are held to discuss and review the residents’ The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 21 care plans. Staff meetings are held on a regular basis. Staff spoken with and records showed that in general regular supervision is being provided. A social worker said that the staff support the residents well. Staff spoken to on the day of the visit said “ I love it here,” “it’s a good place to work”, the residents get “a very good service.” An induction and foundation training programme is provided to all new staff. The training covers health and safety matters, adult protection, equal opportunities, working with adults with a learning disability and promoting the rights of the resident. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. There is a dedicated training budget and a planned programme of staff training. Recent training courses attended by staff included: Principles of Care and Risk Assessments, Food Hygiene, Holistic Approach towards Physical Intervention, Active Model Support, Therapeutic Intervention and Social Inclusion. At present 26 of staff have an NVQ 2 in Care, which includes training around caring for people with a learning disability. A number of staff are working towards this qualification. Specialist training is provided to staff to assist them to support residents as appropriate. Training is provided to staff around equal opportunities. A sample of records of recruitment were seen and indicated that all the required information was available. A record should be made of the interviews of staff. The competence of staff to meet the needs of individuals from minority groups should be assessed during the interview process. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. The welfare of residents is promoted by the quality assurance systems in operation. Residents are not fully supported by the arrangements for training night staff in fire safety. EVIDENCE: There is currently no registered manager for the service. The acting manager has recently decided not to apply to be the registered manager and the position has been advertised. The acting manager will remain the manager of the home until another manager is appointed and then will return to the post of team leader. This will ensure continuity for residents and staff. The acting manager has undertaken periodic training to maintain and update her knowledge skills and competence There are a range of quality assurance systems in place. Visits to the home by The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 23 the representative of the registered provider are made on a monthly basis and a copy of this report is sent to CSCI. An annual review of the service is carried out. Inclusive Lifestyles has obtained the Investors in People award. The views of residents are obtained by key workers and the manager. There are plans in place to increase the involvement of residents in how the home operates, for example, by their being involved in the staff recruitment process. The views of parents and social and healthcare professionals are obtained through regular contact and attendance at meetings concerning residents. A more formal means of seeking these views is currently being looked at. It is recommended that questionnaires be used to find out these views, which would allow for the outcomes and the home’s responses to be recorded together with an action plan for future development. The home notifies CSCI of significant incident/accidents to the residents or events in the care home and what action has been taken. A current Public Liability Insurance was displayed. There are clear lines of accountability with the acting manager and external management of the care home. The records relating to the checks of the electrical wiring, contractors checks of the fire equipment and safety checks of hoists were seen and were in order. The records of fire equipment checks indicated that the fire alarm and emergency lighting are tested at appropriate intervals and that fire drills take place on a regular basis. A fire risk assessment that has been agreed with the fire service was available. The records of fire safety training for night staff showed that some staff had not received this training in the last 2 years. The acting manager agreed to attend to this matter with urgency. It is recommended that fire safety and prevention training be provided to night staff on a 3 monthly basis and to day staff on a 6 monthly basis. The safety certificate for the lift and gas safety certificate were not available during this visit and the acting manager agreed to forward a copy of these certificates to CSCI. The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 24 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 2 2 2 3 X 4 X 5 2 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 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The registered persons must ensure that the services provided by the home are clearly identified in the statement of purpose. Timescale for action 04/05/07 2. YA2 14 The registered persons must 04/04/07 ensure that a full assessment of a residents needs and compatibility with others living at the home takes place before a new resident is offered a service. The registered persons must ensure that a record of the care home’s charges to residents, including any extra amounts payable for additional services not covered by those charges and the amounts paid by or in respect of each resident be kept at the home. The registered persons must ensure that behaviour management plans clearly indicate the action to be taken by staff to manage incidents of self-harm and aggression towards others. DS0000059613.V296641.R01.S.doc 3. YA5 17 04/04/07 4. YA6 15 04/04/07 The Merchant`s House Version 5.2 Page 26 5. YA20 13 The registered persons must ensure that the practices for administering medication safeguard residents at all times. The current practices must be reviewed to ensure that they fully safeguard residents. 04/04/07 6. YA20 13 The registered persons must 04/04/07 ensure that a record is made of all medication leaving and being received at the home to ensure there is no mishandling. The registered persons must ensure that medication administered to residents is recorded (previous timescale of 13/04/06 not met). The registered persons must ensure that correspondence, reports, records of disciplinary action and any other records in relation to a member of staff’s employment is held at the home. The registered persons are to provide a copy of the safety certificate for the lift and gas supply to CSCI. The registered persons must ensure that all staff receives fire safety and prevention training at suitable intervals. 04/04/07 7. YA20 13 8. YA23 17 04/04/07 9. YA42 23 04/05/07 10. YA42 23 04/05/07 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 Good Practice Recommendations DS0000059613.V296641.R01.S.doc Version 5.2 Page 27 The Merchant`s House 1. Standard YA1 It is recommended that the service users guide and further policies be made available in formats that are more suitable for the people for whom the home is intended. The service user guide and statement of purpose should outline how the needs of individuals from minority groups can be met within the service. It is recommended that a photograph of each resident be attached to the medication administration record sheets. It is strongly recommended that a record be made of the reason why a safeguarding adults referral is not accepted by the Local Authority. 50 of care staff are to hold an NVQ qualification or equivalent. A record should be made of the interviews of staff. The competence of staff to meet the needs of individuals from minority groups should be assessed during the interview process. It is recommended that questionnaires be used to find out the views of parents and other stakeholders about the operation of the service. It is recommended that fire safety and prevention training be provided to night staff on a 3 monthly basis and to day staff on a 6 monthly basis. 2. YA1 3. 4. YA20 YA23 5. 6. YA32 YA34 7. YA39 8. YA42 The Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Merchant`s House DS0000059613.V296641.R01.S.doc Version 5.2 Page 29 - 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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