Inspection on 17/10/05 for Mabbs Hall Nursing Home

This inspection was carried out on 17th October 2005.

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 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 11/06/07

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 7DA Lead Inspector Jane Offord Announced Inspection 17th October 2005 10:15 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 DS0000024618.V259721.R01.S.doc Version 5.0 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. DS0000024618.V259721.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mabbs Hall Nursing Home Address High Street Mildenhall Suffolk IP28 7DA 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 Gillian Elizabeth Robinson Care Home 29 Category(ies) of Dementia (29), Old age, not falling within any registration, with number other category (29) of places DS0000024618.V259721.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 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 ensuite 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. DS0000024618.V259721.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday between 10.15 and 16.30. The registered manager and area manager were available to assist as required throughout the day. During the day three residents’ records and care plans, three staff files, the complaints log and the system for managing residents’ personal allowances were seen. Part of a medication administration round was observed, a tour of the premises was undertaken including several of the residents’ rooms, some bathrooms and the kitchen and several residents, two visitors and a number of staff were spoken with in the course of the day. Prior to the inspection the Commission for Social Care Inspection (CSCI) office had received comment cards from four residents and nine relatives/visitors. The majority of responses indicated satisfaction with the service being offered. On the day of the inspection the home was busy but calm. Some residents were using the communal rooms and others had chosen to remain in their bedrooms. Staff were interacting respectfully and appropriately with residents and visitors. What the service does well: The environment is attractively decorated and furnished. Everywhere was clean, bright and airy. Care plans seen were comprehensive with clear interventions recorded which were updated and evaluated regularly. Daily records were good with reference to residents’ moods and psychological state as well as their physical needs. The induction records of staff and the ongoing training programme showed a wide cover of subjects and skills. A recently appointed deputy manager is taking the lead in clinical care and is developing areas of special interest such as an oral hygiene assessment and updating care of diabetic residents. There is a weekly programme of activities that is managed by an activities coordinator. In addition special events are celebrated and outings undertaken. The co-ordinator also spends some time with individual residents who may not want to participate in group activities. Several residents and visitors commented on the high standard of the food in the home. The lunch that was served looked well presented and appetising. DS0000024618.V259721.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. DS0000024618.V259721.R01.S.doc Version 5.0 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 DS0000024618.V259721.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 People who use this service can expect to have their needs assessed and be able to visit the home prior to making the decision to move in. EVIDENCE: The residents’ files seen had documented evidence of pre-admission assessments being done. Areas of need covered physical, psychological and social. The manager has developed, and is introducing, a new pre-admission assessment tool that has detailed, scored needs under the headings of ‘Activities of Living Need’, ‘Behaviour Needs’, ‘Daily Nursing Care Needs’, ’Multi Disciplinary Care Needs’ and ‘Social Needs’. One resident who has been in the home for a number of years said they were ‘very happy here’. Some friends had found the home and visited on their behalf as they were unwell at the time but they have ‘not looked back since arriving’. They have their own routine that the staff manage for them. DS0000024618.V259721.R01.S.doc Version 5.0 Page 9 A visitor who spoke to the inspector said their relative received ‘brilliant care’. Their relative has complex nursing needs and the staff have shown great patience in meeting them. They said ‘I can go home knowing my relative is happy’. The visitor had been shown around the home before their relative was admitted and has been given their own code to enter the front door to come and go as they please. DS0000024618.V259721.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use this service can expect to be treated with respect, have their needs identified in their care plan and met, and be protected by the policies in the home for managing medication. EVIDENCE: The residents’ care plans that were seen covered areas of need such as mobility, personal hygiene, pain, pressure sore prevention, nutrition and nighttime needs. The care plans had evidence that they were all evaluated at least monthly. Interventions identified things that the resident could do for themselves to maintain their independence. ‘Can clean their own glasses’, ‘Can comb their own hair’. There were records of other professionals involved with each resident such as GP, Community Psychiatric Nurse (CPN), Dentist, Chiropodist and Parkinson’s Disease Specialist Nurse. There was evidence of risk assessments being done for falls, tissue viability and the ability to self medicate. Moving and Handling assessments were done with details of the safe way to assist a resident who had poor mobility. DS0000024618.V259721.R01.S.doc Version 5.0 Page 11 Staff were observed knocking on doors before entering rooms. Residents were assisted with their meals sensitively and conversation between residents and staff was relevant and caring. Staff responded to any request for help promptly and willingly. Part of a medication administration round was observed. The trolley was securely locked each time the nurse left it and the Medication Administration Records (MAR sheets) were completed correctly with no signature gaps seen. Medication was given to residents at a pace they could manage and in a form they could easily swallow. The Controlled Drugs (CD) record was checked. CDs for two residents were counted and tallied with the record in the CD register. It was noted that the index in the CD register did not list all the drugs kept in the cupboard. When this omission was pointed out to the nurse they immediately corrected it with the deputy manager. DS0000024618.V259721.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service can expect to be given choice about the way they spend their time and be encouraged to maintain contact with family, friends and the community if they wish. They can also expect to have a well balanced diet. EVIDENCE: Throughout the day residents were observed in all areas of the home and staff were overheard asking people which room they wanted to go to. In the late afternoon a few residents took advantage of a sunny spot just outside the front door and were greeting visitors as they arrived. During the afternoon a noisy game of Bingo took place in the main lounge. There was laughter and cheering and prizes were awarded. The activities coordinator had been out to select some toiletries and chocolates as prizes during the morning. There is a weekly activities programme, which the activities co-ordinator manages. There is a wide range of pastimes offered including arts and crafts, board games, quizzes, professional music afternoons and Karaoke. DS0000024618.V259721.R01.S.doc Version 5.0 Page 13 Residents have access to the local library and therapists visiting the home offer massage and aromatherapy. Special occasions are recognised, so there is a pantomime group booked for Christmas time and a very successful B-B-Q was held during the summer. Family and visitors are welcome at any time and during the day were observed in the main rooms and residents’ bedrooms at the choice of the resident they were visiting. Details of the next of kin and contact numbers were recorded in all the files seen. The menus supplied with the pre-inspection questionnaire looked varied and well balanced. The main meal of the day offered a choice of two dishes. The meal served on the day of inspection looked appetising and hot. The chef said that fresh fruit and vegetables are used and there is a delivery daily. Freshly baked cakes are offered at teatime each day. All the residents spoken with talked of the good quality of the food. One visitor said their relative had had a problem swallowing that had limited their diet to a small number of foods that could be tolerated. They said that the staff had taken a great deal of time and care over helping their relative who was now able to manage a wider choice of food and gaining weight. Residents can choose where they would like to have their meals served. Meals being taken to residents who were not eating in the dining room were being carried around the home without covers on the plates. DS0000024618.V259721.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service can expect that any complaint will be taken seriously and investigated and that the staff have received training in recognising and dealing with abusive situations. EVIDENCE: The home has a complaints policy that is accessible to residents and visitors. One visitor said they would go directly to the manager if they had any concerns and they named the manager. The complaints log was seen and contained details of one complaint made since the last inspection. Details of the investigation and action taken were recorded. The training records of the staff seen contained evidence that Protection of Vulnerable Adults (POVA) training had been done and the pre-inspection questionnaire showed that the training is repeated annually. Ancillary staff are invited to any training taking place at the home and the chef said they had attended POVA training. Other staff were able to explain the process for recognising and referring a potentially abusive situation. DS0000024618.V259721.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 People who use this service can expect to live in clean, pleasant surroundings that are safe and well maintained, have access to specialised equipment to help maintain their independence and have their own belongings around them in their bedroom. EVIDENCE: The home has recently had some of the corridors and communal rooms decorated. The effect is bright and pleasant. The corridors feel wide and spacious. Most areas of the home are carpeted. The furniture and curtains coordinate and there is a variety of styles of armchairs. Individual bedrooms have different colour schemes. There were no unpleasant odours on the day of inspection. The garden has recently had some redesigning work carried out and offers an attractive accessible area for residents to use. It is a secluded garden that is not overlooked. There are plans to further develop it next year with planting to offer a sensory area. DS0000024618.V259721.R01.S.doc Version 5.0 Page 16 Each resident’s room has ensuite facilities consisting of a toilet and hand basin. There are a number of communal bathrooms and toilets that were all clean and tidy. There was evidence of adaptations to raise toilets, and bath hoists to help people with reduced mobility gain access. Residents’ rooms were furnished to suit them with the furniture arranged as they chose. Some residents had their own television or music centre and a lot had personal photographs and pictures on display. Hand washing facilities were all equipped with liquid soap and paper towels. There is an Infection Control policy in place and staff were able to explain the procedure for managing soiled linen. DS0000024618.V259721.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 People who use this service can expect to be cared for by a team that are sufficient in number and competent to meet their needs, however they cannot be assured that all the correct checks will be made before employing staff. EVIDENCE: The duty rotas seen showed that there is at least one trained nurse on duty throughout the twenty-four hours with five carers on an early shift, four on a late shift and two at night. In addition there are domestic staff, maintenance staff, kitchen staff, an administrator and an activity co-ordinator. Staff spoken with felt that there was enough staff on each shift to meet the needs of the residents. The staff files seen had all got a photograph of the staff member, a job description and contract, two references and evidence of Criminal Records Bureau (CRB) checks. One file contained proof of identity in the form of photocopied birth certificate and passport. The other two files did not contain any proof of identity of the staff member. The training records were comprehensive. A full induction programme was in each file and the subjects covered were confirmed in discussion with members of staff. All staff had received training in Health and Safety, Moving and Handling, fire awareness, Control of Substances Hazardous to Health (COSHH) and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). DS0000024618.V259721.R01.S.doc Version 5.0 Page 18 Other subjects covered in training in the past year have been managing challenging behaviour, nutrition, using a syringe driver, wound care, food hygiene and understanding dementia. Staff said the training programme was good and they could suggest subjects of interest to be included in future sessions. Some staff are undertaking NVQ level 2 in care and this is supported in the home. The chef has done training to become an NVQ assessor and will be able to assess staff. DS0000024618.V259721.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 36, 37, 38 People who use this service can expect that the management of the home is positive and open, that their finances will be safeguarded and that their health and safety will be protected. EVIDENCE: The registered manager is approachable and available to staff and residents alike on a daily basis. They are committed to improving care and recently appointed a deputy manager who has the lead on clinical care. Improvements in care planning have been ongoing and an audit of the care plans takes place regularly with the key worker. The system used to manage the residents’ personal allowances was inspected with the help of the manager. Receipts are kept safe and each resident has a separate bag for the balance of their money. Several balances were checked and tallied with the records. The manager has the only key to the safe. DS0000024618.V259721.R01.S.doc Version 5.0 Page 20 The manager readily produced all records and policies requested for inspection. Staff files were kept locked up but policies and procedures were available for staff to access. Residents’ files were kept in the nurses’ office. Staff said they receive supervision regularly and this was supported by documentary evidence in the staff files. The kitchen was clean and tidy. Records were kept of temperatures of refrigerators and freezers and these showed they were within the safe range for food storage. Food stored was labelled and dated. All chemicals in the kitchen area were stored correctly according to COSHH guidelines. DS0000024618.V259721.R01.S.doc Version 5.0 Page 21 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 X X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 3 3 3 DS0000024618.V259721.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? None 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 OP9 Regulation 13 (2) Requirement The Controlled Drugs register must be correctly completed to show in the index the drugs in use. Proof of identity must be obtained prior to employment and a record kept in staff files. Timescale for action 17/10/05 2 OP29 19 (1)(b)(i) 17/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP15 Good Practice Recommendations The final wishes of residents should be ascertained and recorded. Plated meals being taken around the home should be covered. 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