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Inspection on 24/01/06 for Madeira House Nursing Home

Also see our care home review for Madeira House Nursing Home for more information

This inspection was carried out on 24th January 2006.

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.

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 home provides a good standard of care and they maintain a high standard of hygiene. They provide a balanced and wholesome diet in comfortable and spacious surroundings. Relatives are made welcome and their previous caring roles are respected by staff. Resident`s safety and rights are protected by robust policies and procedures relating to personal finances, adult protection and infection control.

What has improved since the last inspection?

Since the last inspection the home have made improvements to the standard of assessment completion. The home now clearly demonstrate the level of consultation with residents about their care plans, and they have made improvements to the information contained in the care plans and all assessed needs are reflected. All staff files now contain proof of identity.

What the care home could do better:

One requirement remains outstanding from the previous report regarding the provision of epilepsy training. The manager said that she is currently trying to locate a suitable course. Some recommendations were made in the interests of good practice and these were relating to the home undertaking risk assessments regarding the placement of hand sanitizers in corridors as there is a potential risk to residents, keeping a record of personal property for each resident and that care plans reflect the level of social activity that residents engage in.

CARE HOMES FOR OLDER PEOPLE Madeira House Nursing Home 129-131 High Holme Road Louth Lincolnshire LN11 0HD Lead Inspector Wendy Taylor Unannounced Inspection 27th January 2006 09:30 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 Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Madeira House Nursing Home Address 129-131 High Holme Road Louth Lincolnshire LN11 0HD 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) 01507 607452 01507 601246 Ancyra Health Limited Mrs D E Parratt Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (55), Terminally ill (3) of places Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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) 20th June 2005 Date of last inspection 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 accommodation for up to 58 people over the age of 65 years. There are three beds available for palliative care needs. 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 accommodation 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 Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2006 and was conducted by two inspectors. There were two recommendations made at this inspection and no requirements. There is one outstanding requirement from the previous inspection. The two inspectors spent time talking to residents, visitors and staff. A selection of records were looked at and a tour of the building was made, including resident and staff files. Many of the key standards were assessed at the previous visit and have therefore not been looked at during this visit. What the service does well: What has improved since the last inspection? What they could do better: One requirement remains outstanding from the previous report regarding the provision of epilepsy training. The manager said that she is currently trying to locate a suitable course. Some recommendations were made in the interests of good practice and these were relating to the home undertaking risk assessments regarding the placement of hand sanitizers in corridors as there is a potential risk to residents, keeping a record of personal property for each resident and that care plans reflect the level of social activity that residents engage in. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 6 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. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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 Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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 The home assures residents that their needs can be met by way of a comprehensive assessment process. EVIDENCE: Four residents files were looked at and all contained initial assessments. Individual sections were completed including Waterlow and nutritional assessments. There were individual review sheets for each part of the assessment, which show that they are reviewed monthly. The assessments include areas such as breathing, eating and drinking, psychological needs and a dependency profile. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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 the following standard(s): 7,8,10 Residents benefit from a good standard of care however care plans do not reflect the efforts that the home makes to address social needs EVIDENCE: Care plans were in place to address needs such as communication, personal hygiene, nutrition and moving and handling. There was evidence that the plans are reviewed monthly and signed by either the resident or their relatives. The completion of personal property inventories was not consistent and end of life arrangements had not been completed. The home has an activity co-ordinator and records are kept of the social activity provided, however care plans do not contain information about social needs. Residents and visitors said that staff always knocked before entering their rooms and checked with them about how they like to be addressed. They said that they felt staff respected their privacy and dignity at all time, and that they would recommend the home to others as they were very satisfied with the level of care. Care plans reflect the need to maintain privacy and dignity. Visiting health professionals said that the standard of care within the home was good. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 10 Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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 the following standard(s): 13,15 Residents enjoy a balanced and wholesome diet. Relatives are made very welcome and their previous caring roles are respected and acknowledged. EVIDENCE: Visitor spoken to during the inspection said that they were always made welcome and they were able to visit at any time that was suitable for the residents. Residents said that they could have visitors when they wanted. Staff demonstrated awareness of the family carer’s need to continue to feel involved and invited them to take meals with their relatives and join in with activity. Residents said that they enjoyed the food at the home, and menus were varied and balanced. There was a relaxed atmosphere in the dinning room and tables were nicely laid. There is ample room for staff to sit with those residents who need assistance with meals. Nutritional assessments are in place on individual files. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 12 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): 16,17,18 Residents are protected by comprehensive complaints and adult protection arrangements, and from a knowledgeable staff team. EVIDENCE: Residents and relatives said that they would feel confident about raising issues of concern and they said they are confident that the home would deal with them appropriately. There are policies and procedures in place concerning complaints, adult protection and whistle blowing and staff demonstrated their knowledge of the reporting procedures. They were also able to demonstrate awareness of how to recognise abusive situations. Records demonstrate that staff have received training in adult protection issues. Residents said that they receive their polling cards and staff support them to exercise their right to vote. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 13 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): 22,26 Residents benefit from the provision of equipment which helps to maximise independence and personal safety. The home provides a hygienic environment and knowledgeable staff. EVIDENCE: Staff were observed to be using appropriate equipment to enable residents to move safely, such as hoists, wheelchairs, specialist seating and adjustable beds. There are also specialist baths, grab rails and bed rails in use where appropriate. The home has a moving and handling policy and there are moving and handling assessments on individual files. The home was found to be clean and tidy on the day of the visit. There are policies regarding infection control, clinical waste and protective clothing. Staff were seen to use protective clothing and to carry out hand washing where required. There are hand sanitizer machines placed around the home in corridors for staff to use but there are no risk assessments in place. Records show that staff receive training in infection control procedures. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 14 Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 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 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): 27,28,29,30 Staff are well trained and able to meet resident’s needs, although they would benefit from training in some specialist needs. Recruitment practices are robust and safeguard residents. EVIDENCE: Staff files contained information required by the National Minimum Standards including references and Criminal Records Bureau checks. A member of staff described their recruitment process and this was in accordance with the home’s policies. Staff described structured induction training including fire safety, infection control and moving and handling. Training for staff regarding the management of epilepsy was discussed with the manager. She said that she is currently trying to locate a suitable training course. The home operates a key worker system and those key workers spoken to showed a good knowledge of the physical, emotional and psychological needs of the residents. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 16 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): 33,35 Residents are protected by sound procedures for their personal finances and their health and safety needs are promoted. EVIDENCE: The home has a comprehensive quality assurance policy. There was evidence of an annual residents survey carried out in January 2006. The home has recently introduced a new system for surveys, this includes more focused surveys that will be carried out every two months for issues such as meals, daily living, environment and laundry. There is also a format specifically for visitors feedback. The home has policies and procedures in place for the Control of Substances Hazardous to Health and those substances were stored and monitored appropriately. An issue regarding hand sanitizers is reported upon in Standard 26. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 17 Records relating to residents money that is kept by the home were satisfactory and money and any valuables were kept securely. One resident said that their finances are managed by power of attorney and another by a relative. Other residents said that they manage their own money. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 18 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP30 Regulation 18(1)(c) (i) Requirement 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. Some work has been done to source the training but further work is required. A new timescale for action has been set. Timescale for action 30/06/06 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 OP7 Good Practice Recommendations It is recommended that care plans clearly reflect social needs and the activity that the home provides to meet those needs. It is recommended that the home complete inventories of DS0000002542.V279488.R01.S.doc Version 5.1 Page 20 Madeira House Nursing Home 3 OP26 personal possessions for all residents and they clearly record end of life arrangements/wishes on individual files. It is recommended that the home complete risk assessments for the placement of hand sanitizer machines in corridors. Madeira House Nursing Home DS0000002542.V279488.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Lincoln Area Office 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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