Inspection on 20/02/07 for Madelayne Court

This inspection was carried out on 20th February 2007.

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

Madelayne Court 26/01/09

Madelayne Court 15/01/08

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Madelayne Court School Lane Broomfield Chelmsford Essex CM1 7DR Lead Inspector Diana Green Key Unannounced Inspection 20th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Madelayne Court Address School Lane Broomfield Chelmsford Essex CM1 7DR 01245 443986 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) runwoodhomes.co.uk Runwood Homes Plc Manager post vacant Care Home 112 Category(ies) of Dementia - over 65 years of age (112), Old age, registration, with number not falling within any other category (112) of places Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 112 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 112 persons) The total number of service users accommodated in the home must not exceed 112 persons The registered person must not admit persons subject to the Mental Health Act 1983 or the Patitents in the Community (Amendment) Act 1995 Staffing levels to be reviewed within six months of date of registration Date of last inspection 7th November 2006 Brief Description of the Service: Madelayne Court provides personal care with accommodation for up to 112 older people. The home is also registered to care for service users with dementia. Madelayne Court is owned by Runwood Homes PLC. The home is located in Broomfield, a village type locality on the perimeter of Chelmsford, Essex. The home is a three-storey building that was purpose built and first opened in 2006. There are 112 single en-suite bedrooms on three floors that are accessible by stairs and three lifts. There are 41 single en-suite rooms on the ground floor, divided into three units, 50 single en-suite rooms on the first floor divided into 3 units and 21 single en-suite rooms within one unit on the second floor. Each unit has a lounge and dining room. There are six bedrooms with adjoining doors to accommodate shared accommodation for three couples if required. The gardens surrounding the property are laid mainly to lawn with established trees and are fenced. Gardens to the rear of the property have paved areas and raised beds that are accessible to wheelchair users. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 5 The home is on the main bus route. The home is accessible by car and the nearest railway station is nearby. Parking is available for staff and visitors in the large car park located to the rear of the home. The fees range from: £426.09 -£650. per week Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 4/04/07 Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection since registration of the home. Two inspectors undertook the inspection on the 20/02/07 and lasted 8.5 hours. The inspection process included: discussions with the manager, deputy manager, the operations manager, the cook, the laundry assistant, both activities coordinators, eleven residents, thirteen care staff, five visitors and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty-seven standards were inspected and five requirements and nine recommendations made. The manager, deputy manager and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? This was an unannounced inspection and the first key inspection since registration of the home. Following concerns raised a random inspection was undertaken on 7th November 2006 and four requirements made with regard to personal and health care, moving and handling equipment and training and recruitment procedures. At that time it was clear that the home was having Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 7 some difficulties following its opening 6 weeks previously and this had, in some cases, affected the health and welfare of residents. It was also evident that the manager had an open and honest approach and was working hard to address the issues raised. A new deputy manager has since been appointed and action taken to address the requirements made. The home is now working closely with health and social care colleagues to promptly address any issues. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 8 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 Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 1, 3, 4 and 5. Residents were well informed, had their needs assessed prior to moving in to the home. Changing/developing needs were assessed to ensure they were appropriately met. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that met regulatory requirements. Prospective residents and or their representatives were provided with copies prior to admission. Some were observed in Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 10 residents’ rooms and copies were displayed in the entrance of the home for visitors’ information. Pre-admission assessments were carried out by the manager or deputy manager. Care team managers who had NVQ level 3 or had received in-house training also undertook some pre-admission assessments. Where possible arrangements were made for the person who assessed the client to be the person to welcome them into the home on their day of arrival. A sample preadmission assessment form was seen, and included a basic dementia assessment (mental status questionnaire). Discussions were held with the manager regarding a person recently admitted who exhibited aggressive behaviour and was non-co-operative with staff: this information had not been given to the home by the family or social worker and the home were reviewing whether they can meet their needs in the home. The home does not provide intermediate care. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 7, 8, 9 & 10 The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed. Residents’ privacy and dignity is in the main upheld but closer monitoring of individual residents is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of seven files were viewed that included dementia and non-dementia service users. All files contained an assessment form completed on admission and used to trigger care plans. This form contained standard categories of need, each with a range of descriptors selected by tick boxes. No additional information had been recorded on the form, and this format does not therefore accurately describe individual levels of need and ability. However, additional Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 12 individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, pressure areas, etc.), and it was positive that these being regularly reviewed. However, a continence assessment viewed had not been fully completed, although the individual had significant needs in relation to their continence. The only assessment form for issues relating to dementia was a basic mental state questionnaire. An appropriate range of care plans were present on the sample of files viewed, and these generally contained a good level of detail of the action required by staff to help the person meet their needs. It was positive that care plans highlighted the need to promote choice and identified what people could do for themselves. There were care plans addressing mental health/behavioural needs, although none of those viewed provided information on the triggers causing behaviours. On the file of one person who had challenging behaviour, there were no specific records monitoring these behaviours, although they were referred to in daily notes. Feedback from some relatives indicated that staff did not have time to spend with residents and they had to wait to receive personal care. Care files include nutrition assessments, residents were being weighed regularly (and weights recorded), and the deputy manager reported that individual records of nutrition and fluid intake were maintained (not viewed on this occasion). Where residents showed agitated behaviour, staff had varied skills in dealing with this appropriately and effectively. On one unit it was noted that there were several residents whose behaviour could be quite demanding. Staffing levels need to be kept under close review to ensure that staff have sufficient time to give to these individuals. On the day of the inspection it was observed that there was input into the home by GP, district nurses and dentist, and that emergency services were called when required (e.g. when someone had a fall). However a link community psychiatric nurse had not been provided as promised. The home had a medication/clinical room; this housed a drug fridge. It was not used for medication storage but had been allocated for use by district nurses and for GPs to see residents. A much smaller room was used to store the medication but was too small to enable staff to check medicines on receipt from the pharmacy. An air conditioning unit had been installed and monitoring of temperatures showed that temperatures were within recommended levels (25°Centigrade). The home had medication policy and procedures that were available for staff guidance. The procedures provided clear guidance to staff with exception that they did not clearly indicate the need to record the name and address on receipt and disposal for controlled drugs. The deputy manager/care team managers administered all medication at the home and had all received appropriate training. Medication was supplied through a local pharmacy in pre-dispensed packs and appropriate ordering and disposal procedures were followed. Medication administration records (MAR) were well Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 13 recorded. Advice was given to ensure that for prescribed creams, only the person administering the cream must confirm by signature. Medication profiles were recorded for individual residents. However these were incomplete and did not always record the reason for the medication being prescribed. Care files contained clear information and indicated each person’s preferred name. Staff were noted to treat residents with courtesy and dignity; however, there were a few instances where residents in communal areas were seen with their clothes ridden up, compromising their dignity: staff should closely observe residents throughout the day to prevent this happening. A resident spoken to was seen to have a key to their room with them, and others confirmed they could have a key to their door. Feedback was received from residents and relatives indicating there was good access to healthcare and prompt referrals to GPs. Residents and their representatives said that care staff were caring and respectful staff at all times, had empathy with residents and always supported them with sensitivity. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15 The social and therapeutic activities are in need of further development to meet residents’ needs including those with a dementia. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many of the resident’ files viewed contained a social history or family tree, providing a good profile on the person, and information on their past interests. Files also contained care plans relating to activities, which was good to see. The home employs two part-time activities organisers, both of whom showed interest in their work, and were co-ordinating a range of activities during the week (e.g. games, art and crafts, musical bingo, etc.). Neither activities organiser had much previous experience of direct work with older people with Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 15 dementia, and should be supported to access appropriate training to develop their skills and knowledge. Evidence of an activities programme was seen displayed in the home, and individual records were maintained of service user involvement in the activities. However, all the residents spoken with felt that there was ‘not much going on’: this was discussed with the manager in relation to the time available to the activities organisers, and the importance of care staff also remaining responsible for initiating activities with residents (not seeing this task as the remit of the activities staff) and supporting activities staff when activities are taking place (i.e. not leaving them alone in lounges where residents may need assistance). The activities staff were not aware of there being any budget for the home for the purpose of booking entertainers and trips out, and had been told they would need to fund raise to pay for such events. The manager affirmed that central budgets were available for organising activities, and needs to ensure that activities co-ordinators are supported to access these. Feedback received from relatives indicated there were not enough stimulating activities provided and more ‘one to one’ activities were needed. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. Staff reported that one resident’s spouse was able to join them for lunch each day. A church service is held in the home each month, and staff reported that some local community groups had visited the home at Christmas (e.g. bell ringers, local school children carol singing). Relatives said that reception staff were very welcoming. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, meals, etc. One Care Team Manager spoken to explained that residents could have breakfast in bed if they did not want to get up for breakfast, saying that this was important as ‘it’s their home’! This was good to hear. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them, and residents were seen to be able to have keys to their room, in order to give them control over their personal space. Some married couples’ needs for autonomy over their lives were promoted through the accommodation provided (e.g. two adjoining rooms, used as bedroom and lounge). Information on advocacy services was included in the statement of purpose and available in the home. The home had established links with the Alzheimer’s Society locally. Residents spoken with were generally positive about the meals served at Madelayne Court. The main meal served on the day of the inspection looked and smelt appetising, and residents observed were enjoying this. Hot drinks were seen being served during the day, and water jugs were seen in residents’ rooms. A menu was observed displayed in a dining area, and the manager reported that copies of the menus are provided in residents’ rooms. The home operates a four weekly menu: this was a corporate menu that had been developed for Runwood Homes following an analysis of the nutritional content Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 16 of a sample of menus previously in operation at various homes, in order to ensure an appropriate nutritional input for residents. The chef advised that he was able to adapt the menus to reflect local residents’ preferences, and confirmed that the home had appropriate systems for ensuring satisfactory food stocks (re quality and quantity). Menus viewed showed an appropriate range of meals, with choices available at all meals: it was good to see residents being able to make their choices at the mealtime (i.e. they did not have to choose beforehand). The chef showed good knowledge of the nutritional needs of older people, and of meeting special dietary needs (e.g. diabetes). It was suggested to the chef and the manager that, where residents were able to serve themselves, they could consider providing serving dishes on tables for items such as vegetables. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 16 & 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. Residents spoken to were clear that they felt able to tell someone if they had any concerns. The homes’ record of complaints detailed the investigation and action taken as a result. Ten complaints had been received since the random inspection regarding concerns with poor standards of personal and health care, lack of dignity, low staffing levels, lack of staff training, lack of equipment, missing personal items, competency of care staff and manager’s attitude. All had been investigated and appropriate action taken where relevant. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. The records confirmed that staff had received training in protection of vulnerable adults. One Care Team Manager spoken to confirmed Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 18 that they had received POVA training: she was able to list different types of abuse, understood the concept of institutional abuse, and was clear about the procedure to follow if any concerns were reported to them. There was always a manager on call for advice. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled standards 19, 22, 24 & 26 Madelayne Court is clean and hygienic and aims to provide a safe, well maintained a homely environment but some health and safety risks prevent this always being achieved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms, the sluices, clinical room and the laundry. As the home was recently registered, records of decoration and refurbishment were not discussed. The home was in a good state of décor and repair. The home has a full time maintenance person. Evidence of checks by the fire officer and environmental health officer were seen at the time of Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 20 registration in 2006. Feedback received from residents indicated they felt safe and secure. The home had passenger lifts to enable access throughout the premises and to the gardens. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Designated storage areas for equipment were provided. Call systems were provided throughout all individual and communal rooms. Pressure relieving equipment was available and the district nursing service also provided specialist mattresses. Some staff provided drinks in mugs rather than cups that some residents found too heavy to hold and were evidently not aware of this. The home was seen to have a copy of a guidance document on Infection Control in Residential Homes, as well as its own health and safety policies and guidance. The home employs laundry staff (50 hours per week) and housekeeping staff assist in the laundry when required. The laundry area was clean and well organised, with separate areas for clean and dirty laundry. Sluice facilities were located on each floor of the home. Macerators have been installed in each for maceration of disposable commodes/urinals. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines; washing machines had the capacity to carry out sluice wash cycles. Laundry staff reported that soiled items are sometimes found within the normal laundry: care staff must ensure these are kept separate. It was noted that washing machines appeared to have 60°C and 90°C wash temperature options: the laundry person was not aware of any facility to carry out a wash at 65°C or 73°C for infection control purposes, and stated that most washes (including red bag contents) were carried out at 60°C. Laundry staff wore re-usable rubber gloves, cleaned with antiseptic hand wash, rather than disposable gloves for handling laundry. As there is a risk of contact with blood and bodily fluids, gloves must be single use disposable and of the same standard as those required for undertaking personal care. External clinical waste bins were stored in a secure area but were overflowing and unlocked (reference also standard 38). Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled standards 27, 28, 29 & 30. The staffing levels (skill mix, number and competence) were not always appropriate to the needs of residents. Recruitment practices were thorough and promoted the protection of service users. Staff are able to develop skills and qualifications through an established training programme but this is sometimes compromised by a lack of staff continuity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care Team Managers spoken with felt that current staffing levels enabled them to meet residents’ needs, although a Care Team Manager on the first floor felt that they were at a point when any further increase in resident numbers would require additional staffing. They felt able to raise concerns about staffing levels with the manager and deputy manager. There were times during the day when it was noted that there were no staff in lounge areas with residents, and activities staff reported that on occasions they had been left on their own with groups of residents, and were not able to deal with any care needs that arose. It was also noted that on one floor there were several residents whose needs resulting from their dementia (e.g. agitation, shouting out, etc.) required quite Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 22 a lot of attention from staff. Staffing levels need to be kept under review to ensure that the care of other residents is not compromised where this occurs. Feedback was received from relatives that there had been staffing shortages and a lack of continuity and communication problems had resulted in disruption of residents’ bathing routines. The manager reported that an increase in staffing levels had been agreed commencing the following day. Feedback was also received from residents and their relatives that many staff were invaluable but there was a lack of experienced staff. The home had 3 care staff (including 2 bank staff) with NVQ level 2 training and five care staff with NVQ level 3. A further 17 staff had applied to undertake NVQ level 2 and 5 for NVQ level 3. The percentage of staff with NVQ level 2 training was therefore less than 50 needed to meet the standard. The recruitment files of three recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards (records were not inspected). The home had an established training programme. Three Care Team Managers spoke positively about an 8-week dementia course they had undertaken and said they had learnt a lot from this. The majority of care team managers and care staff had only received one day training on dementia awareness and would benefit from a more comprehensive training. Staff spoken to (mainly Care Team Managers) confirmed they had completed training on Protection of Vulnerable Adults, fire safety, and moving and handling and this was also confirmed from the records inspected. Training had also been provided on first aid, health and safety and food hygiene. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 31, 33, 35, 36 & 38 The manager is supported well by senior staff in providing clear leadership throughout the home with most staff demonstrating a good understanding of their roles and responsibilities. The manager aimed to ensure good health and safety standards but some practices were evident that pose risks to service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a registered nurse with 25 years experience in both the private and nursing sector. She has had previous experience in commissioning and Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 24 managing care homes. She holds the NVQ level 4 /Registered Managers Award. CSCI have not as yet received an application for registration. The manager is supported by a deputy manager who has ten years experience in the care sector. He also has previous deputy management experience in a care home within the organisation. The deputy manager planned to commence the registered managers’ award during May 2007. There is a corporate quality assurance programme whereby an annual audit is undertaken of Runwood care homes. The quality team had worked with the care staff team to assist in the development of the service since its recent registration but as yet no quality audit had been undertaken. The home monitored all complaints and compliments and also had a suggestion box for residents and visitors. Relatives meetings had been held monthly since the home was registered. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped ‘pouches’. Two residents’ records were inspected, and records, receipts and cash all balanced. The administrator confirmed that valuables are not generally stored on behalf of residents, and therefore no specific systems were in place for this. A Care Team Manager spoken to confirmed that they have one-to-one supervision with their manager approximately every 3 months, and that these sessions were recorded. They reported that managers currently still supervise care assistants, but that it was planned for Care Team Managers to sit in on supervisions in order to learn the process and take on the care staff supervisions. The home had a health and safety policy manual (inspected at registration), and staff had attended relevant health and safety training. The manager and deputy manager are currently the individuals responsible for health and safety in the home, but intend to also train the maintenance person to share the responsibility. Some risks to health and safety (standard 26) were evident that pose a risk to staff and service users. As the home was newly built and equipped in September 2006 it was still within it’s first six months of operation, and therefore not all utilities or equipment were due a service yet. However, evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. evidence of certificates obtained when the building was completed, PAT testing done in January 2007, etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 25 There was a comprehensive fire risk assessment: this was not signed, but the manager stated that it had only just been received from their head office. There was evidence that two fire drills had taken place in the last six months, although the manager stated that they were planning to carry out six fire drills per year and expected all staff to attend at least one. Drills to date only covered a small sample of staff, and the manager was advised to implement systems to ensure and monitor that all staff attend fire drills. There was a comprehensive file of risk assessments covering generic work tasks for staff, and including use of chemicals. Risk assessments included reference to Legionella and hot water storage temperatures, but there were no systems in place for monitoring that hot water was being stored at over 60 °C (reference also standard 25). The manager was advised of the need to include this in the routine checks carried out in the home. Clinical waste bins stored outside the building were in a secure area but were not locked as required (reference also standard 26). Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 26 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 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 2 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 2 Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 12(1) & 16(2)(m) & 16(2)(n) 13(3) 13(3) & 18(1) 13(3) & 13(4) 13(4) Requirement Social and therapeutic activities must be further developed to meet all residents’ needs including those with dementia. Laundry staff must wear single use disposable gloves when handling laundry. Laundry staff must receive training on infection control practices when processing laundry. Eternal clinical waste bins must be locked at all times. Implement monitoring of water temperatures to ensure they are near to 43°Centigrade. Timescale for action 30/09/07 2. 3. OP26 OP26 30/04/07 30/04/07 4. 5. OP38 OP25 30/04/07 30/04/07 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 OP7 Good Practice Recommendations Additional relevant information should be detailed on the assessment form to describe individual levels of need and DS0000068095.V331219.R01.S.doc Version 5.2 Page 28 Madelayne Court 2. 3. 4. 5. 6. OP7 OP7 OP8 OP9 OP9 7. 8. 9. OP12 OP12 OP22 ability. A home aiming to care for people with dementia should have more comprehensive tools for assessing memory, cognition and behaviours. Care plans and records relating to challenging behaviours should be further developed to provide evidence they are monitored. Provide further training for all care staff in dementia care practices to ensure they are skilled in dealing with agitated behaviours. A review of medication storage should be undertaken to provide sufficient accommodation that does not pose a health and safety risk. A review of medication procedures should be undertaken to clearly indicate the need to record the name and address in the dedicated register on receipt and disposal for controlled drugs. Activities coordinators should receive training on the provision of social and therapeutic activities for older people. Social and therapeutic activities programmes should combine a cohesive approach between care staff and activity coordinators. A range of crockery and utensils should be available to meet residents’ (dexterity) needs. Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Madelayne Court DS0000068095.V331219.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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