Inspection on 20/06/05 for Madeira House Nursing Home

This inspection was carried out on 20th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Madeira House Nursing Home 10/07/07

Madeira House Nursing Home 27/04/06

Madeira House Nursing Home 24/01/06

Madeira House Nursing Home 22/11/04

Madeira House Nursing Home 27/05/04

Madeira House Nursing Home 13/10/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Madeira House 129-131 High Holme Road Louth Lincolnshire LN11 0HD Lead Inspector Wendy Taylor Unannounced 10:00 20 June 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. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Madeira House Address 129-131 High Holmes Road Louth Lincolnshire LN11 0HD 01507 607452 01507 601246 N/K Ancyra Health imited 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 D Parratt Care Home (CRH) 58 Category(ies) of Old Age, not falling within any other category registration, with number (55) of places Terminally Ill (3) Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is Registered to provide personal care with nursing for service users of both sexes whose primary needs fall within the following categories: (OP) (55 beds) Palliative Care (terminal illness) (TI) (3 beds) Date of last inspection 22 November 2004 Brief Description of the Service: Madeira House is a care home, which also provides nursing care for residents. It is owned by Ancyra Health Limited. The registered manager is a State Registered Nurse who has worked at the home since it opened in 1986. The home offers care and accomodation to 58 people over the age of 65 years of age. The home is situated on the outskirts of the market town of Louth, and is on a bus route into the centre of town. It is a large two storey building offering accomodation to residents on both floors. There is a passenger lift giving access to the first floor. The home benefits from well maintained gardens and has ample parking space to the rear of the building.. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2005. There have been two additional visits to the home since the last inspection and the timescales for requirements made at the additional visits have not yet expired. A tour of the building took place and resident and staff files were looked at. Seven residents, three relatives, four staff and one visiting health professional were spoken to. Positive comments such as, ‘the staff are lovely’, and ‘mother has settled very well’, were made. Observation of the care provided, and general interactions between residents and staff took place throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The residents would benefit from more robust completion of care records, and although staff training generally meets the needs of residents there are areas of training that would enhance care provision if provided. Please contact the provider for advice of actions taken in response to this Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Madeira House C53 C04 2542 Madeira 227257 200605 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 Madeira House C53 C04 2542 Madeira 227257 200605 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) 2,3 Residents benefit from clear contracts and terms and conditions, but individual files could contain more explicit information as to the level of care that is provided. Whilst there is a comprehensive assessment format in place, there is a need to ensure that all sections are completed thoroughly. EVIDENCE: There were contracts and terms and conditions available for all residents, which are held in the main administrative office. Eight resident’s files were looked at. All files contained initial assessments but not all of the assessments were completed thoroughly, for example dates of completion were not filled in, review sheets had not been completed and Waterlow/Nutrition assessment scores were not filled in. There is a requirement from an additional visit in regard to assessments that remains in this report. There was no indication on files as to what level of care had been funded e.g. nursing or personal care. The manager said that she has discussed the issue of Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 9 the provision of nursing procedures to residents who are funded for personal care only. She said that she is awaiting a protocol that the District Nurses have agreed to draft. A discharge policy is now in place. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 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 standard(s) 7 - 11 Resident’s benefit from a good standard of care however the home is unable to demonstrate that identified care needs are met for all residents due to incomplete care records. EVIDENCE: Seven out of eight files looked at had care plans in place including, communication, personal hygiene, eating and drinking and elimination. Care plans did not always follow on from the initial assessments for example, dietician input for high-risk nutrition assessment and care plans for tissue viability on high risk Waterlow assessments. Risk assessments did not always link to care plans for example; one file did not contain a nutritional risk assessment although this was an identified need. Arrangements for death and dying needs were completed and signed by relatives. Medicine records were completed satisfactorily and administration procedures were carried out appropriately. There were no residents self-medicating at the time of the inspection. A visiting health professional said that there was a good standard of basic care within the home, however there is a need for the home to adhere to the wound Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 11 management formulary in relation to pressure sore dressings. The formulary was available in the home. Residents said that staff are ‘very nice’ to them, they ‘make time to speak’ to them and they get them whatever they want. They also said that staff knock on their bedroom doors before entering and talk to them in private about their care needs. Relatives said that they were happy with the standards of care within the home. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 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 standard(s) 12 - 15 Resident’s benefit from being able to make choices in all aspects of their lives, and from being offered appropriate activities and social contacts. They also benefit from a nutritionally balanced diet. EVIDENCE: Residents said that they have access to activities such as bingo, in-house entertainment and various outings, and can choose whether they join in or not. The home has employed a new activity co-ordinator. There were people visiting residents throughout the inspection and relatives said that they could visit when they wish. They also said that the home provided ‘very good support’, and it is a ‘brilliant home but there does not appear to be enough staff’ (see Staffing section of this report). Menus were available and demonstrated a choice of foods. Kitchen staff had a good knowledge of resident’s likes and dislikes and a list was available in the kitchen. The lunchtime meal was well presented and staff encouraged a relaxed atmosphere in the dinning room. Residents said that they enjoy the food that is provided and that they are able to choose what they want to eat. One resident said that there is always an alternative if she doesn’t like the main menu. Madeira House C53 C04 2542 Madeira 227257 200605 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) 16 - 18 Residents benefit from comprehensive complaints and adult protection procedures; and from the homes’ responses and co-operation with the investigation processes. EVIDENCE: Since the last inspection one complaint has been received by the Commission for Social Care Inspection (CSCI), which was subsequently referred to the Local Authority Adult Protection Co-ordinator. The issues raised were in regard to standards of care within the home. Requirements and recommendations were made as part of the investigation process and are included in the relevant sections of this report. Timescales for compliance with the requirements have not yet expired. During this inspection staff demonstrated their knowledge of the procedures for reporting adult protection issues and complaints. Policies and procedures for reporting complaints and adult protection issues are available in the home. A requirement was made during the additional visit on 04/03/05 with regard to keeping records of all concern and complaints made to the home. Madeira House C53 C04 2542 Madeira 227257 200605 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) 19,20,23,24,25,26 Resident’s benefit from a choice of areas within the home in which to spend their time. They enjoy generally safe, well-maintained and pleasant surroundings, although there may be risk from some fire safety precautions. EVIDENCE: On the day of the inspection the home was seen to be clean and tidy, and décor, furniture and flooring was in good order. Resident’s bedroom were personalised, and communal areas were pleasantly furnished and decorated. Five lounge areas are available within the home and furniture is arranged so as to minimise the risk of trips and falls. Garden furniture was in good order and the grounds and gardens were well maintained. Residents and their visitors were making full use of the outside space during the inspection. No issues were raised at a recent environmental health officer’s visit. COSHH materials were stored appropriately and data sheets are available within the home for the products in use. Hoists are available within the home and were last serviced in February 2005. Some doors were found to be wedged open and Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 15 the issue was discussed with the manager. It was agreed that the manager would liaise with the local fire officer for advice in regard to this issue. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 16 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) 27,29,30 Resident’s benefit from well trained staff who are able to meet their needs, but they would benefit further from additional training. Recruitment practices are generally robust and this safeguards the residents. EVIDENCE: There were ten staff on duty across the day of inspection, which included two qualified nurses. The manager demonstrated that the deployment of the staff was based on resident’s needs. Staff said that there were enough people on duty to allow them to do their jobs but they can be busy in the mornings. Six staff files were looked at. The files demonstrated robust recruitment procedures including references, CRB checks and application forms. Identification was missing from one file. Staff spoken to during the inspection said that they experienced a good induction process including the opportunity to shadow more experienced colleagues. There was evidence in training records that the TOPPS induction process is followed. They said that they received structured supervision at least once a month, but they can go to senior staff for support in between those times. They were able to demonstrate clearly how they would manage a report of an adult protection issue and they were aware of the policies and procedures available in the home. Staff said that they had completed training such as fire safety, moving and handling and basic food hygiene, this was confirmed by training records. The manager said that the home is currently doing the gold standard framework for palliative care. She said that the McMillan Nurses are providing training for staff in the near future. It was also confirmed that the Tissue Viability service is to provide training in the near future. The manager Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 17 said that as yet she has been unable to identify a training course for epilepsy but will be looking at in house training using material from the Epilepsy Society. Staff demonstrated a clear knowledge of residents’ needs and said that the keyworker system works well but could be improved by regular meetings between keyworkers and residents. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 18 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) 31,32,38 Residents and their relatives benefit from an open and supportive management approach within the home. Records are well maintained and show that the resident’s health, safety and welfare needs are promoted. EVIDENCE: The registered manager is an RGN with extensive experience in care provision and management. She holds an NVQ Assessors certificate, NVQ Level 4 Management and an OU P553, Systematic Approach to Caring. Residents and staff said that the manager is approachable and they can talk to her at any time. Relatives also said that they are able to talk to the manager about any issues they have. All COSHH materials were stored appropriately and data sheets were available, fire extinguishers had been checked in February 2005 and hoists were serviced in February 2005. Signage for the storage and use of oxygen was available in appropriate places. A fire drill was conducted in May 2005 and an up to date Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 19 fire risk assessment was available. General environmental risk assessments were in place and seen. The annual quality assurance survey is due to be carried out in October 2005. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 20 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 x 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 3 3 x x x x x 3 Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14(1)(2) Requirement The responsible person must ensure that all residents admitted to the home have a complete and comprehensive assessment of need that is completed in consultation with the resident and/or their representative; and the placing authority. The assessment must be reviewed and revised where necessary. This requirement was made on 04/03/05. It is acknowledged that some progress has been made but further work is required. The responsible person must ensure that residents care plans reflect all identified needs and take into account the outcomes of all assessments undertaken. This requirement was made on 04/03/05. The responsible person must ensure that comprehensive records are kept of all concerns/complaints and actions taken in respect of the concern/complaint. The responsible person must liaise with the local fire officer in regard to holding doors open Timescale for action 03/08/05 2. 7&8 15(1)(2) 03/08/05 3. 16 22(3) Schedule 4(11) 03/08/05 4. 25 23(4)(a) 30/09/05 Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 22 5. 6. 29 30 19(1)(b), Schedule 2 18(1)(c) (i) within the home and take any action adivsed by the fire officer. The responsible person must inform CSCI of the outcome. The responsible person must ensure that proof of identity is available on all staff files. The responsible person must ensure that the persons employed to work in the care home receive training appropriate to the work they are to perform, including epilepsy training. This requirement was first set in November 2004. A new timescale for action has been set. 30/09/05 30/09/05 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. 3. Refer to Standard 3 7 Good Practice Recommendations It is recommended that residents files indicate what level of care the resident is funded for. It is recommended that the home follow the wound management formulary provided by the Tissue Viability service. Madeira House C53 C04 2542 Madeira 227257 200605 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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