Inspection on 30/05/07 for The Mulberries

This inspection was carried out on 30th May 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Mulberries 68 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Jean Bovell Key Unannounced Inspection 30th May 2007 11:00 The Mulberries DS0000069517.V340996.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 Mulberries DS0000069517.V340996.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 Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mulberries Address 68 Bath Road Hounslow Middlesex TW3 3EQ 020 8577 6487 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) www.pentahact.org.uk Adepta Mary Bridget Kearney Care Home 7 Category(ies) of Learning disability (7) registration, with number of places The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 7 N/A Date of last inspection Brief Description of the Service: The Mulberries is a purpose built home which provides a service to seven people with profound learning and physical disabilities. It is situated on the ground floor of a two-storey building in Hounslow. Hounslow Central underground station, various bus routes and the local shopping centre are located within easy walking distance. The home consists of seven single bedrooms, large lounge/dining area, Kitchen, utility room and two bath/shower rooms. There is also a staff sleeping-in room with en suite shower and toilet and a rear garden with patio. Wheelchairs are accommodated within the home and there are a variety of specialist equipment suitable for meeting the needs of the people who use the service. The home is owned by Adepta but the Notting Hill Housing Trust holds responsibility for the premises. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11am and 5:30pm on 30th May 2007. The Registered Manager, three members of the care support staff team and three service users were at the home. During the course of the inspection, the home’s records, documents, policies and procedures were viewed, observations were made and a tour of the building was undertaken. Discussions were held with three care support workers and all key Standards were examined. The Registered Manager was co-operative and provided appropriate assistance throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 6 Six requirements were identified at this inspection. These related to the complaints procedure, medication, maintenance, staff training, supervision of residents and quality assurance. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Mulberries DS0000069517.V340996.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 Mulberries DS0000069517.V340996.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records relating to some of the people who use the service were viewed and it was evidenced that prospective residents are appropriately assessed prior to being admitted into the home. EVIDENCE: The records regarding four people who use the service were inspected and it was reflected that comprehensive needs leds assessments and background history in relation to prospective residents were submitted to the home at the point of referral. It was indicated also, that subsequent assessments were carried out by the home and that relatives, previous carers, care managers and health professional were involved in the process assessing and determining the capacity of the home to meet specific personal, healthcare, diatary, social and cultural/religious needs. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A number of completed ‘support plans’ were viewed at random and it was evidenced that the changing needs of the people who use the service are being satisfactorily assessed. It was also indicated that related risk assessments are being carried out and are clearly detailed. The records were reflective of residents being assisted in making decisions in relation to their daily living routines, where appropriate. EVIDENCE: The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 10 The Inspector was informed by the Registered Manager that the personal files of the people who use the service were in the process of being updated. A number of files that had already been updated were examined at random and it was evidenced the separate personal, healthcare, social, diatary and religious/cultural needs had been assessed within ‘support plans’ and that actions and goals had been put in place. Risk assessments were carried out in relation to separate activities identified within care plans and included moving and handling, use of wheelchairs, use of bean bags and use of public transport. It was indicated that ‘support plans’ and risk assessments would be regularly reviewed. Although the people who use the service receive personal care and are nonverbal, they are encouraged - with assistance - to make decisions regarding their daily living routines. It was reflected within ‘support plans’ that residents received assistance in making decisions regarding personal purchases, what they wore, meals and activities. Care support workers were observed being able to interpret and respond appropriately to requests that were made by specific sounds and body language and resulted in residents being escorted, in their wheelchairs, to activities within the local community. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 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. 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. The social, religious and cultural needs of the people who use the service are being met satisfactorily and they are able to take part in the local community. Contact with relatives and/or advocats is encouraged and facilitated and residents rights are being respected. Varied and wholesome meals are provided at the home. EVIDENCE: Activities Programmes were in place and it was reflected that the people who use the service attended the day centre on various days each week. Residents were also taken to Sunday Church Services and participated in various other The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 12 activities within the community such as swimming, bowling, day trips and annual holidays. Residents were also taken to restaurants which reflected cultural preferences. Four residents attended the day centre and three were escorted to an activity within the community at the time of the inspection. The home has an open visiting policy and the Registered Manager confirmed that the residents received regular visits from their respective relatives and/or advocats. The people who use the service occupy separate bedrooms in which personal interests and choices are reflected. The menus were indicative of varied and nutritional meals being provided at the home. The people who use the service require assistance with feeding. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records regarding several residents were viewed at random and it was evicenced that the people who use the service receive overall personal assistance and that their physical and emotional needs are being met appropriately. The home’s procedures in relation to medication are satisfactory. EVIDENCE: The people who use the service require overall assistance with their personal care routines and these tasks are carried out in privacy within bathrooms or individual bedrooms. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 14 The healthcare needs of the residents were set out within their separate records and were being met appropriately. Weight charts were maintained and it was evidenced that relaxation therapies were provided and that all residents received physiotherapy on a daily basis. Although the administration, storage and disposal of medicines were found to be satisfactory, dates of opening bottled medicines had not been recorded. The people who use the service do not have the capacity to administer their own medication. The records indicated that medication training had been delivered to all members of the care support staff team. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure satisfactory detailed but had not been updated to include current CSCI contact details. Policies and procedures on Adult Abuse are in place but staff training on POVA had not been delivered. EVIDENCE: The complaints procedure was appropriately detailed and accessible to the people who use the service and their relatives. However, it had not been updated to reflect current CSCI contact details. The London Borough of Hounslow’s manual on the Protection of Vulnerable Adults was in place. The records indicated that the Registered Manager had received training on the Protection of Vulnerable Adults. It was not evidenced that POVA training had been delivered to the members of the care support staff team. This was discussed with the Registered Manager who gave assurances that the required training would be arranged. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately maintained, the atmosphere is homely and pleasant but general redecoration and refurnishment - in particular areas – is required. EVIDENCE: The home is spacious, comfortably furnished and appropriately equipped for meeting the needs of the of the people who use the service. However, general redecoration is required and floor coverings – particularly in the kitchen and dining required cleaning or replacing. The Registered Manager confirmed that a programme of refurbishment and redecoration had been agreed with the Notting Hill Housing Trust. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 17 The garden was adequately maintained. Issues in relation to the laundry were not identified. Overall the home was found to be clean, hygienic and safe. The atmosphere was calm and homely. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care support staff are, overall, appropriately trained and qualified to meet the needs of the people who use the people who use the service but training on the Protection of Vulnerable Adults is required. Residents were not being satisfactorily supervised at the time of the inspection. The home’s recruitments policy and practices are appropriate for the protection of people who use the service. EVIDENCE: The Inspector was informed by the Registered Manager that three members of the care support staff team had obtained level 2 National Vocational Qualification. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 19 A number of personnel files were viewed at random and were found to contain all the required documents. It was reflected on training certificates that staff training delivered during 2006 included Moving and Handling, Epilepsy Awareness and Administering of Rectal Medication, Dysphagia, Fire Safety and Mediation. It was not evidenced POVA training had been delivered. The ratio of care staff to residents was appropriate at the time of the inspection and care support staff who were on duty were observed satisfactorily meeting the needs residents while they were being fed and responded appropriately to their indicated requests by escorting them to an activitiy within the community. People were, however, left unsupervised while they sat in wheelchairs in the lounge and no physical or verbal engagement or interation were observed being initiated by staff. Care support staff were at the time observed being involved in various practical tasks and all attended a staff meeting that was held in the dining area on the afternoon of the inspection. These observations were discussed with the Registered Manager. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is appropriately trainined and qualified. Systems for effective quality assurance were not evidenced. The health and safety of the people who use the service are being satisfarily safeguarded. EVIDENCE: The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 21 The home was taken over by a new provider following the last inspection and the Registered Manager has been in her current position since September 2006. The Registered Manager has had fifteen years experience in the social care field and has achieved NVQ level 3. The Inspector was informed by the Registered Manager that she had recently enrolled for training on the Registered Managers Award. The records indicated that the Registered Manager had also receivied recent training in Perfornance Management, Appraisal Systems and Disciplinary Financial Procedures. Members of the care support staff team who were spoken with expressed various views and opinions regarding the changes in work practices that were being implemented. These included additonal activities within the community for the people who use the service and increased volume of paper work/task expectations. The Registered Manager explained that her fundamental aim was to improve the quality of the service being provided to the residents. Systems for quality assurance were not seen to be in place at the time of the inspection. However, the Registered Manager confirmed that meetings for relatives and advocats at whic held on a three monthly basis. The records were reflective of all health and safety checks being up to date. Environmental risk assessments had been carried out and were clearly and appropriately detailed. The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 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 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 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 2 X X 3 X The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 23 N/A 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 YA20 Regulation 17(3)(a) Requirement Timescale for action 14/06/07 2. YA22 3. YA24 4. YA35 5. YA35 The Registered Person must make sure that dates of opening are recorded and signed on the labels of all bottled medication. 22(7)(a) The Registered Person must ensure that CSCI contact details are updated on the complaints procedure. 23(2)(d) The Registered Person must make sure that communal areas are redecorated and that floor coverings in the kitchen and dining area are cleaned or replaced to ensure that the required standards are being maintained. 18(1)(c) (i) The Registered Person must make sure that POVA training is delivered to all members of the care support staff team to ensure that the needs of residents are being met appropriately. 12(5)(b) The Registered Person must make sure that people who use the service receive appropriate quality attention from care support staff to ensure that good personal/professional relationships are maintained. DS0000069517.V340996.R01.S.doc 01/08/07 30/10/07 01/09/07 14/06/07 The Mulberries Version 5.2 Page 24 6. YA39 24(1)(a)(b) The Registered Person must make sure that effective quality assurance is carried out for reviewing and improving the quality of care provided at the home. 30/09/07 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 Standard Good Practice Recommendations The Mulberries DS0000069517.V340996.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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