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Inspection on 28/04/05 for Mabbs Hall Nursing Home

Also see our care home review for Mabbs Hall Nursing Home for more information

This inspection was carried out on 28th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The statement of purpose and service user guides were available in the home for visitors and prospective residents. The home is well managed, with staff supervision and regular staff meetings undertaken, therefore ensuring that staff are made aware of issues in the home and are given support from their peers. Care plans were comprehensive, with the residents health care needs identified. In particular, the home has introduced nutritional assessments for those residents who are at risk from weight loss. In addition, the chef has developed a nourishing milkshake to give those residents between meals to supplement food intake.

What has improved since the last inspection?

The home operates a good service, with the manager leading the team with the development of care planning, training and the recruitment of staff. The home have replaced carpets in three bedrooms, two lounges and decorated parts of the home. The manager has reviewed the record keeping in the home particularly the archiving systems.

What the care home could do better:

The home is operating at a good level therefore at this inspection there were no requirements or recommendations made.

CARE HOMES FOR OLDER PEOPLE Mabbs Hall Nursing Home High Street Mildenhall Suffolk IP28 7DA Lead Inspector Iain Smith unannounced 28th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mabbs Hall Nursing Home Address High Street Mildenhall Suffolk IP28 7DA 01638 712222 01638 712155 None MNS Care PLC Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Gillian Robinson CRH 29 Category(ies) of OP - 29, DE - 29 registration, with number of places Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10th January 2005 Brief Description of the Service: Mabbs Hall is a purpose built care home, located in the centre of the town of Mildenhall, off the main High Street. The home accommodates for up to 29 service users, some of whom may have dementia and nursing needs. The accommodation is situated on two floors, with 25 single and two double rooms. The floors are linked by a passenger lift, therefore, giving service users access to all areas of the home. The garden is enclosed at the rear of the home and there is ample car parking at the front and side of the building. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was arranged as an unannounced inspection, the first inspection in the year 2005/2006. The visit commenced at 11.50 and lasted 3.10 hours during which time the inspector spoke to staff including the administrator, deputy manager and chef. The manager was present throughout the visit and fully contributed to the inspection process. Time was spent with six residents over the inspection period speaking with them about a range of subjects including meals, activities and care. A tour of the premises was made, rooms and communal areas were visited, two care plans and two personal files were examined. What the service does well: What has improved since the last inspection? The home operates a good service, with the manager leading the team with the development of care planning, training and the recruitment of staff. The home have replaced carpets in three bedrooms, two lounges and decorated parts of the home. The manager has reviewed the record keeping in the home particularly the archiving systems. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 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. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4 and 5. People who use the service receive clear information to enable them to make the choice about whether they might wish to live in the home. EVIDENCE: Both the statement of purpose and service user guides were available to residents. They were displayed in the foyer to the home in addition to being sent to prospective residents. The two care plans examined included a contract, signed by the resident’s representative. One care plan examined included a pre admission assessment. The health care needs of the resident were assessed. Staff, through the training and development, have the individual and collective skills to deliver the services and care which the home provide. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,9 and 10 There was evidence that all residents care needs were assessed and care planning was completed with medication systems in place to ensure safe working practices. EVIDENCE: Two care plans were examined to assess if the residents care needs were identified and the methods for the delivery of the care, considering the risk assessments and specialist care requirements. The care plans stated clearly the care needs of each individual. In one care plan the risk assessments for manual handling were included. The care plan then identified that the resident required full assistance with transferring from bed to chair. There was an explanation of the equipment required therefore ensuring that all staff followed the same practices. The nutritional assessments were included in both care plans. There were 14 probable risks and one care plan stated that the resident requires a soft diet. The instructions were for the resident to be assisted with the eating and drinking due to the inability to swallow. This demonstrated the care plan was clear with instructing staff to care for that individual resident. Weight charts were evidence that each resident was monitored for a fluctuation in their Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 10 weight. A number of resident’s who were assessed as at risk with their weight, had a diet recording sheet that staff would complete following each meal. The system was for the staff to assess the intake of each selected resident and record as a percentage of 100 of the meal eaten. This enabled the staff to assess the overall food intake. This was assessed as an excellent initiative as part of the resident’s health assessment and care. The procedure for the Medication Administration Record (MAR) was assessed and found to be relevant. The nurse administering the medication was observed to check the MAR sheet, select the medication, administrate and then sign following each resident taking the medication. This was assessed as the accepted practice for the administration of medication. All staff were observed to address the residents politely and with respect. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14 and 15. The home offers daily activities and encourages residents to fulfil their social, cultural and recreational interests. Meals are planned and prepared specifically to meet the needs of the resident’s likes and needs. EVIDENCE: The resident’s care plans stated individual’s likes and interests. The activities that were organised for the residents included combined games, draughts, connect 4 and cards. Two residents stated that they enjoyed playing cards with the activities person. The activities events are displayed in each of the resident’s bedrooms, in the front foyer and the main notice board. The manager stated that the home organised a dance around the maypole. The lunchtime was observed. Residents were sitting at dining tables and three were seen to require some assistance with their meals. The lunch was displayed on the menu board in the dining room. The meal was either cottage pie or pork steak with rich gravy. Apple crumble or ice cream was the sweet. The chef has introduced a nutritional milkshake for people who have been at risk through ill health or loss of weight. This is given to the residents approximately 2 hours following their meal. The manager stated that residents weight had increased and records demonstrated this. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 12 The manager indicated that the home is involved in nutritional groups and the diabetic specialist from the local hospital visits the home to give instruction in Diabetic care. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 13 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 standard(s) EVIDENCE: No standards were assessed from this section. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,25 and 26. The home was generally clean, tidy and warm with a pleasant and varied décor throughout the home. The lounge and dining areas provide for the residents needs and ensures that people have the flexibility to sit where they wish. EVIDENCE: The home is welcoming, with the administrator available to greet people on entry to the home. The environment was clean and each area was decorated and carpeted. The small lounge area was in the process of being painted and the manager stated that there were plans to develop the grounds leading from this area. The main lounge area had recently been redecorated, new carpet fitted and the fireplace tiled. Another new carpet had been fitted in Bedroom 3, 4 and 15. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The procedures for recruitment are robust and staff files contained all relevant information gathered prior to staff commencing employment. The staffing was sufficient in numbers and skill mix that was reflected on the staff rota. EVIDENCE: The staff rota was examined and found to have sufficient staff allocated for the home and to meet the care needs of the residents. The manager was supernumerary, with a registered nurse in charge of the shift. The afternoon and night shift also had an allocated registered nurse, a requirement for a nursing home. A deputy manager had recently been appointed, this was assessed as a positive move to ensure the home had the appropriate management support when the manager was away from the home, also, as an additional team member to release the manager from responsibilities, for example training. There were five care staff in the morning, four for the afternoon shift and two at night showing on the staff rota. This is in addition to the registered nurse on each of the shifts. There were allocated laundry personnel, an administrator, maintenance person, the chef and an activities member of staff. All of these staff were correctly recorded on the staff rota. The two staff files examined each evidenced the correct information required to recruit staff. This included an application form, two references and an enhanced Criminal Records Bureau (CRB) check. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 16 Staff training was in evidence, information was included in both the files that were examined and in individual records. The deputy manager was responsible for arranging the training since her appointment and the manager prior to the appointment. The training was relevant for the home and the care of the residents. Examples of the training were Diabetic care, clinical wound management and understanding dementia. The management has recently set up a resource centre for both the students and permanent staff in the home to access learning resources. This was assessed as a positive initiative to further develop the staff to gain the skills required to care for the residents. Staff supervision was undertaken on a two monthly basis, this included registered nurses, care staff and ancillary staff. Records were seen for one member of staff and the manager stated that all staff has regular supervision. Three staff that were spoken to each verified this to be the case. Record keeping was appropriate in the home. Staff files were kept safe and secure in addition to all residents files were securely locked when not in use. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38. There was clear leadership within the home to ensure that residents receive consistent quality care through staff training and communication. Practices and the environment help promote and safeguard the health, safety and welfare of the people who use the service. EVIDENCE: The manager is a registered nurse in addition to in excess of two years, management experience and a number of appropriate courses. There was evidence of monthly staff meetings. Two staff stated that all staff meet and discuss issues in the home including activities and training. Minutes form the meetings were seen. The manager stated that the company support her in the management of the home and assist in enabling the progress and development of the practices and environment. This demonstrates the manager is able to influence the management of the home for example with the recent appointment of the Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 18 deputy manager. One member of staff stated that ‘the manager is very approachable’. Staff supervision was undertaken on a two monthly basis, this included registered nurses, care staff and ancillary staff. Records were seen for one member of staff and the manager stated that all staff have regular supervision. Three staff who were spoken to each verified this to be the case. Record keeping was appropriate in the home. Staff files were kept safe and secure in addition to all residents files were securely locked when not in use. Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 x x 3 3 3 Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 5th Floor St Vincent House 1 Cutler Street Ipswich Suffolk, IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mabbs Hall Nursing Home I54-I04 S24618 Mabbs Hall V227416 050428 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!