Inspection on 11/06/07 for Mabbs Hall Nursing Home

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mabbs Hall Nursing Home 03/06/09

Mabbs Hall Nursing Home 17/10/05

Mabbs Hall Nursing Home 28/04/05

Mabbs Hall Nursing Home 10/01/05

Mabbs Hall Nursing Home 12/07/04

Mabbs Hall Nursing Home 19/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Henrietta House

Firstlings

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

CARE HOMES FOR OLDER PEOPLE Mabbs Hall Nursing Home High Street Mildenhall Suffolk IP28 7EQ Lead Inspector Deborah Kerr Unannounced Inspection 11th June 2007 09:00 X10015.doc Version 1.40 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 Mabbs Hall Nursing Home DS0000024618.V343017.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 Older People. 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. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mabbs Hall Nursing Home Address High Street Mildenhall Suffolk IP28 7EQ 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) 01638 712222 01638 712155 MNS Care PLC Vacant Care Home 29 Category(ies) of Dementia (29), Old age, not falling within any registration, with number other category (29) of places Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Mabbs Hall is situated in the centre of Mildenhall with easy access to the local shops and other facilities. The service offers accommodation to twenty-nine older people some of whom may have nursing needs or dementia. There are twenty-five single rooms and two double rooms over two floors that are connected by a passenger lift. All the rooms have en suite toilet and washbasin facilities. On the ground floor there is a large lounge and a dining room. There is also a smaller lounge, which looks over the gardens and has level access to the outside. There is car parking available in the front of the building. Each of the people living at the home has a contract of terms and conditions; which reflect the fees and how much they are expected to pay per month. Fees range from £370 plus the Registered Nursing Care Contribution (RNCC) rate up to £650 per week. These charges do not cover additional services such as the hairdresser, chiropodist and personal items such as toiletries, daily newspapers and personal transport. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and half hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including a pre inspection questionnaire. A number of records were inspected, relating to people using the service, staff, training, the duty roster, medication, health and safety and a range of policies and procedures. A tour of the home was made and time was spent talking with the manager, four staff, eight visitors and a six people living in the home. What the service does well: What has improved since the last inspection? The home has been awarded a capital grant from Suffolk Association of Independent Care Providers for improving the care environment for older persons. This grant is being put towards the cost of further work in the gardens to the rear of the house. One of the people living in the home has a keen interest in gardening and has nominated themselves as the chairperson for a committee involving people living at the home and relatives to decide how the money will be spent. So far suggestions have included additional paving for wheelchair users to access the gardens and raised flowerbeds. Two requirements were made at the previous inspection for the controlled drugs register to be completed to show the index of drugs in use and for proof of identity to be obtained prior to employing new staff. Inspection of these documents confirmed that these requirements have been met. Mabbs Hall Nursing Home DS0000024618.V343017.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 summary of this inspection report can be made available in other formats on request. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People who use the service experience excellent quality outcomes in this area. Prospective people choosing to move into the home and their relatives have the information needed to make an informed choice to decide if the home will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a detailed statement of purpose; service user guide and brochure, which includes colour photographs and information setting out the aims and objectives of the home and the services provided. These are in the process of being updated to reflect the new manager. The manager is also considering providing this information on an audiocassette for people with a visual impairment. Prior to moving into the home each person has a pre admission assessment completed. These provide detailed information about the individual’s health, social and personal care needs. People’s files showed that the manager had written to the individual confirming their placement at the home stating that they are able to meet the person’s individual health and social care needs. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 9 The home employs six qualified nursing staff, including the manager who are supported by a team of seventeen care staff. Individually and collectively they have the skills and experience to meet the needs of the people living in the home. Staff files and training records confirmed that staff have received recent training in wound care, tissue viability, diabetes, falls prevention, infection control, challenging behaviour and Intercare medication training. People’s files contained the necessary paperwork setting out the terms and conditions of residence, the method of payment and their current fee. Consent forms signed by the individual and/or their relative gave the home permission to obtain the National Health Service (NHS) funding for the Registered Nurse Care Contribution (RNCC). The form agreed to the funding to be paid directly to the home. For one individual funded by Social Services an Individual Placement Contract (IPC) was seen which confirmed the level of funding including the RNCC and the individual’s contribution. Information obtained during discussions with people confirmed that they are given the opportunity to visit the home before deciding to move in. One person commented “ we looked at other homes, but we found Mabbs Hall to be the best, my relative has never said, I wished I never moved here, the staff are very friendly and helpful” another person added “when we visited, we walked through the door and all we could smell was cooking which helped us to make the decision this was the home for our relative”. The home does not provide intermediate care; subsequently this standard is not applicable. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, People who use the service experience good quality outcomes in this area. The health and personal care people receive is based on their individual needs, although they cannot be assured that at the time of serious illness, death or dying their wishes will be respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of four people living in the home were inspected. These contained a current photograph of the person together with their personal details including next of kin and other important contacts. The plans are well organised, divided into eleven sections, which provide information covering all aspects of the individual’s health, personal and social care needs. However, a plan relating to the individuals end of life needs including death and dying, had not been completed. This needs to identify an established plan where people requiring palliative care, to manage degenerative and terminal illness, have systems in place which constantly monitors their pain, distress and other symptoms to ensure the individual receives the care they need in accordance with their wishes and religious beliefs. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 11 Although this is a sensitive subject this information needs to be ascertained and agreed with the individual to ensure that at the time of their death, staff will treat them and their family with care sensitivity and respect. One of the plans has been completed using a new format, which the manager is monitoring with a view to using the best information from the old and new format to produce a detailed and person centred plan. The new care plans have introduced using a traffic light system, which is a moving and handling assessment, identifying the level of support required by the individual. Each person is assessed to identify which category of red, amber or green they meet. Red indicates that staff must refer to the moving and handling assessment prior to any transfers, amber suggests proceed with caution and refer to assessment if unfamiliar with the person, whereas green indicates the person is fully able to assist with the transfer. Nursing plans and assessments are in place, which are designed to promote as well as monitor the individual’s health and well being. The plans inform staff of the level of assistance required by the individual to provide their care and support whilst encouraging them to maximise their independence and selfesteem. Assessments include promotion of tissue viability, falls and nutritional screening. These are kept under review with a monthly update recording significant issues on the reverse of each plan. Care plans and a copy of the complaints procedure are kept in people’s bedrooms. Those spoken with confirmed they were aware of their care plan. Daily records confirmed that the health and well being of people is being monitored. Regular visits were documented showing that people are supported to access their general practitioner (GP) and other local health services relevant to them. This includes regular checks to monitor warfrin levels, hospital appointments, chiropodist and opticians. The lunchtime medication round was observed. The home uses the Monitored Dosage System (MDS). Each blister pack had a front sheet with the individual’s details and a photograph for identification purposes. The Medication Administration Record (MAR) charts showed that the day of the inspection was the beginning of the new monthly medication. The process of receipt, administration and safekeeping of medication is well managed. The quantity and date of medication received had been entered on the MAR and signed as correct by one of the nurses. The previous months MAR charts were inspected and were found to be correct with no missed signatures. Where PRN (as required) medication had been administered the date, amount and reason had been recorded on the reverse of the MAR chart. Likewise where blood test result undertaken by the anticoagulant monitoring service recommend a change to the persons prescription for Warfarin, the Warfarin levels had been altered on the MAR chart with the new dose recorded, signed and dated. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 12 The controlled drugs register was seen, confirming that there is currently two people prescribed temazepam. The stock of medication was checked against the register and was found to be accurate. People’s care plans contain a risk assessment to determine if the individual wishes or is able to manage their own medication, and the level of support required to achieve this. Of the four people’s plans seen, they had each chosen to have staff administer their medication. Staff were observed treating people living in the home with respect and dignity. The interactions between the individuals and staff were observed to be friendly and appropriate. Staff were observed calling people by their preferred name and responding sensitively to their individual’ needs and preferences. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, People who use the service experience excellent quality outcomes in this area. People who use this service are able to make choices about their lifestyle, which enables them to live ordinary and meaningful lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s brochure states that Mabbs Hall’s commitment is to provide a service with “The Second Family Concept”. Discussion with people living in the home and visitors, and observation throughout the inspection confirmed that the home achieves this commitment. During the afternoon the inspector observed a game of bingo in progress, with people from the home, staff and relatives. People were observed engaged in conversation with each and there was a lot of laughter creating a jolly and relaxed atmosphere. Visitors were seen arriving throughout the day to spend time with their relative or friend. One person commented “ I have visited the home often and at various times of the day, there is never a difference in the service being provided”. A relative commented, “we are very satisfied with the home, the staff are very good, they are lively and encourage people to be active” and “staff are very helpful providing those extra little touches which make for a personalised service”. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 14 A Mabbs Hall newsletter keeps people living in the home and their relatives informed and up to date with current events and dates of future activities and church services. The home has an activities co-ordinator who plans daily activities, social gatherings and outings. The inspector was shown a folder, containing an activities programme and photographs confirming these events had taken place. The activities include a weekly game of Bingo, with alternate sessions of music bingo, cooking sessions, aromatherapy, crafts, (such as knitting, crocheting and patchwork) combined games and quizzes and carpet bowls. Special events are also organised including live musical entertainment, garden parties, cheese and wine evenings, pub lunches and visits to town shopping. A recent addition to the activities available has been ‘Pet Therapy’ visits to the home. A church service is held at the home on the second Wednesday of every month. A hairdresser was at the home during the inspection and confirmed that she visited the home weekly. People have access to the local library that have a selection of audio books and books with large print. The home has been awarded a grant from Suffolk Association of Independent Care Providers for improving the care environment for older persons. Following a recent meeting with people using the service, relatives and staff it was agreed that the grant is to be used towards the cost of further work in the gardens to the rear of the house. At the meeting a committee was formed with one of the people living in the home, acting as chairperson, to oversee subsequent meetings and planning of the garden. So far suggestions have included additional paving for wheelchair users to access the gardens and raised flowerbeds. People spoken with described the food as “very good” and “food appears appetising and appealing” and “the food is very good especially the breakfast”. The menu for the day of the inspection provided people with a choice of chicken in tomato and mushroom sauce or Newmarket spiced sausages with red wine and onion gravy, with seasonal vegetables and mashed potato. Dessert was a choice of strawberries and cream or ice cream. Some people living in the home choose to buy certain food items themselves or have them brought in by relatives, these were seen being stored in the appropriate places with the individuals names and dates. The lunchtime meal was observed; food served looked appetising and was nicely presented. Discussion with the chef confirmed meals are all ‘home-cooked’ using mainly fresh ingredients. However they commented that they were finding it increasingly difficult to manage the budget and provide a variety of different foods, such as fish, due to the rising costs of food. The Chef felt that the food budget had not increased in line with the cost of food prices. Currently they are managing the budget on a day-byday basis, obtaining local produce, which is in season and readily available. The chef voiced their concern that bringing in a rolling menu will make it more difficult to manage the budget. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, People who use the service experience excellent quality outcomes in this area. People can expect that their complaints will be listened to, taken seriously and acted upon and that procedures are in place, which protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The policies and procedures for dealing with complaints and safeguarding the people living in the home were seen. The pre inspection questionnaire states there has been four complaints made about the service since January 2006. Information taken from the complaints book shows these complaints were documented, investigated and the outcomes feedback to the complainants who appeared to be happy with the outcome. People using the service and visitors spoken with felt the home had an open door policy and felt that they could raise any concerns with the manager and that they would be looked into. One person commented, “I have no concerns about complaining, I feel free to say what I feel, unlike the previous home I lived in”. The procedure for reporting allegations of abuse guides staff to refer all allegations of abuse to Social Services, Customer First Team. The manager was also advised that whilst the procedure remains the same the Vulnerable Adults Protection Committee (PAVC) was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 16 The policies relating to the protection of adults and whistle blowing will need to be amended to reflect this change. Training records confirmed that all staff have attended training to recognise abuse in the home. The pre inspection questionnaire confirms this training is completed annually. The manager showed the inspector a video, which is used for training purposes. Staff are expected to complete a question and answer paper to test their understanding of the information in the video. Staff also demonstrated a good understanding of what constituted as abusive practice and would have no problem reporting an incident or an individual if they had any concerns about their conduct. The home does not manage people’s financial affairs. Each of the people using the service have their finances managed by a power of attorney or their next of kin or their representative. All fees are paid by standing order directly to head office. However the home does hold small amounts of cash for people who request this service. Each person’s money is kept in an individual wallet and full details of monies paid in and withdrawn are entered into a ledger, with receipts. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26, People who use the service experience excellent quality outcomes in this area. People can expect to live in a home that is decorated and presented to a high standard, which is comfortable and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mabbs Hall is situated in the centre of Mildenhall with easy access to the local shops and other facilities. There are twenty-five single rooms and two double rooms over two floors that are connected by a passenger lift. On the ground floor there is a large lounge, a dining room and a smaller lounge, overlooking the gardens, which has level access to the outside. The garden is to the rear of the house. It is attractive and well maintained with a large pergola as a focal point with a range of seating for use when the weather permits. People living in the home and their visitors were observed enjoying sitting and talking in the garden. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 18 People living in the home take an active part in looking after and maintaining the garden, one individual was seen weeding the flowerbeds and informed the inspector that some of the other residents had planted the hanging baskets. The home has a continuous programme of redecoration; the most recent rooms that have been decorated are the lounges, dining room and some of the bedrooms. Furnishings and lighting throughout the home are domestic in character and are sufficient for their purpose. All bedrooms have en suite facilities comprising of a toilet and hand basin. Additionally there are assisted baths, walk in showers and toilets on both floors. Grab rails and other moving and handling equipment, was seen positioned around the home and where required adjustable beds and pressure relieving mattresses had been provided to maximise the individual’s safety, comfort and independence. People’s rooms were nicely decorated and evidence was seen that they had brought their own possessions with them to personalise their rooms. All bedrooms are carpeted and fitted with a call bell, door lock and lockable cabinet for personal items. Internal fire doors around the home were being held open by automatic closures linked to the fire alarm system. All external fire doors are kept closed and are operated by a magnetic key carried by staff in the event of the fire alarm being activated. The home was found to be clean, bright and tidy with no unpleasant odours. The laundry facilities seen were clean and tidy with appropriate equipment to launder clothing and bedding, which comply with the homes own infection control policy and procedure and the Department of Health (DOH) guidelines. Appropriate hand-washing facilities of liquid soap and paper towels are situated in all bathrooms and toilets where staff may be required to provide assistance with personal care. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, People who use the service experience good quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels and training were examined during the inspection and using information taken from the pre inspection questionnaire completed in January this year. The duty roster reflected that each day is covered by a qualified nurse with five carers on an early shift between the hours of 8am – 2pm and a qualified nurse with four carers on a late shift between 2pm – 8pm. Nights shifts are covered by a qualified nurse and a carer between the hours of 8pm – 8am. Additionally there are a number of ancillary staff employed, which includes domestic staff, a maintenance person, kitchen staff, an administrator and an activity co-ordinator. Relatives and staff confirmed that staffing levels are sufficient to meet the needs of the people living in the home. The home operates a good recruitment process, staff files seen were well organised and contained all the relevant documents and recruitment checks, including a Criminal Records Bureau (CRB) and a Protection of Vulnerable Adults (POVA) check. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 20 The files confirmed that the new employees had completed induction training, which included all mandatory training and the Skills for Care Induction. This covers all six standards relating to the principles of care, the role of the worker, health and safety, effective communication, recognising and responding to abuse and develop as a worker. Records confirmed that staff are provided with the training they need to gain the knowledge and skills to perform their work role and meet peoples needs. Between 2006 and 2007 staff have attended training in adult protection, administration of medication, health and safety, control of substances hazardous to health (COSHH), food hygiene, fire safety, challenging behaviour, moving and handling, falls, first aid and infection control. Training more specific to the individual needs of the people using the service has included nutrition, wound care and tissue viability, diabetes and dementia awareness. Figures in the pre inspection questionnaire reflect that 40 of staff have a National Vocational Qualification (NVQ) or have a nursing qualification; therefore the home does not currently meet the National Minimum Standard (NMS) target of 50 of care staff to hold a recognised qualification. Four members of staff are currently undertaking NVQ level 1 or 2. People spoken with were complimentary about the staff and were confident that they met their needs. Comments included “staff are very friendly and helpful” and “staff are splendid I am very happy here” and “ I couldn’t ask for or get better care”. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 38, People who use the service experience good quality outcomes in this area. The home is run in the best interests of the people living in the home, which is tested by an effective quality monitoring system, however where concerns have been identified which compromise the health, safety and welfare of people working and living in the home action needs to be taken to minimise these risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Due to promotion of the former manager within the company a new manager has recently been appointed. Time was spent discussing their qualifications and previous experience. They confirmed that they qualified as a registered nurse in 1991. Since then they have gained a range of experience nursing at various hospitals and nursing homes in the United Kingdom and abroad. They are in the process of making an application with the Commission for Social Care Inspection (CSCI) to become the registered manager for Mabbs Hall. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 22 The manager has been in post for 12 weeks. Feedback obtained through discussion with people using the service, relatives and staff was very positive. Comments included “they are very professional and easy to talk to” and “they are very positive, they have managed very well, they are bubbly and liked by everyone”. The home has good quality monitoring systems in place. The most recent independent survey was conducted in March 2007. The analysis of the survey reflects that out of 18 topics questioned which covered the standard of care, food, environment, staff, accommodation and cleanliness were either very satisfied or satisfied, only four responses were made which were categorised as neither satisfied or dissatisfied. Comments included in the survey requested more books and magazines in large print and the provision of ‘talking books’ and ‘talking newspapers’. The home has used this information and has an arrangement with the local library to supply these items. One person made a comment about the seating around the edge of the lounge, which makes it difficult for people to talk to each other and suggested grouping of chairs. At the time of the inspection the chairs were still around the edge of the room. Consideration should be given to rearranging the chairs in a less institutionalised way, allowing for a range of interests and activities preferred by the people using the service and which would promote conversation. Other comments included “my relative within a week of moving to Mabbs Hall was so different they have blossomed and they are very happy” and “I feel that Mabbs Hall is offering a first class service and do not know where it could be improved”. A copy of the home’s business plan for 2007- 2008, was seen which sets out the facilities, aims and objectives of the home, comparisons with other local providers, a mission statement, financial status and future plans. The aims identified in the plan are to continue to provide a high standard of care, in a homely atmosphere and to ensure the service is provided in a professional manner. Also to ensure that future financial considerations do not conflict with the ethics of providing good care. Although the home does not manage people’s finances, for their convenience the manager does hold a small amount of personal cash. This is held separately for each person and a record of transactions of all monies spent and received are logged. The records and balance for three people were checked and were found to be accurate. During a tour of the home, it was noted that people are provided with safe, lockable cupboards where they can choose to store personal and valuable items if they wish. Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 23 As well as attending the Skills for Care Induction training, new employees complete an in house induction which is a comprehensive guide familiarising the employee with the layout, policies and procedures and health and safety arrangements of the home. Evidence was seen in staff files that these have been completed and supported by supervision. The kitchen was clean and tidy. The food store seen confirmed that the home has a good range of quality foods, which are being correctly stored, labelled and dated. The chef confirmed they had been made aware of the Better Food Safer Business pack, provided by the Food Standards Agency, however they prefer to use own documentation to record temperatures of chilled foods received into the home, refrigerators and freezers and the temperature at which food is served. The records confirmed that the home has good procedures in place for the safe storage, preparation and cooking of food. During the tour of the home a few minor issues relating to the safety and welfare of people living in the home were discussed with the manager. It was noted that that although staff have received training for moving and handling they do not always use the equipment available, which ensures their own health and safety and protects the people in the home from injury. All cleaning products and data sheets with the control of substances hazardous to health (COSHH) information are locked in a cupboard on the ground floor. However, when inspecting the contents of the cupboard, it was noted that carpet shampoo and neutraliser air freshener had been decanted into a smaller plastic containers. The manager was advised that labels with the health and safety information should be attached to the bottle in case of accidental spillage when being used by staff in other parts of the home. Mabbs Hall Nursing Home DS0000024618.V343017.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 4 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 4 4 4 X 4 4 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 4 4 3 X 2 Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP11 Regulation 12(3) Requirement The end of life needs of people living in the home need to be discussed with relatives and/or representatives. This will ensure that in these circumstances the individual and their relatives will be treated with dignity and respect and in accordance with their wishes. Where the home has the equipment and staff have received training the manager must ensure that staff adhere to the moving and handling assessments and use the equipment provided. This will ensure their own health and safety and protect the people in the home from injury. All cleaning materials, which are potentially hazardous, must not be decanted into unlabelled bottles in line with the Control of Substances Hazardous to Health (COSHH) regulations. This will protect the health and safety of people living and working in the home. Timescale for action 31/07/07 2. OP38 13 (4) (b) 13 (5) 12/07/07 3. OP38 13 (4) (a) (c ) 12/07/07 Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 26 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 OP18 Good Practice Recommendations The whistle blowing policy needs to be amended to reflect the same procedure as the protecting adults from abuse policy. These will need to reflect that the Vulnerable Adult Protection Committee (PAVC) was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. To ensure people using the service are in safe hands at all times a minimum of 50 of care staff should hold a recognised qualification such as National Vocational Qualification (NVQ). 2. OP28 Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. Extracts may not be used or reproduced without the express permission of CSCI Mabbs Hall Nursing Home DS0000024618.V343017.R01.S.doc Version 5.2 Page 28 - 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. 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