Inspection on 11/07/07 for Madeleine House

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Madeleine House 22/02/10

Madeleine House 09/11/09

Madeleine House 19/10/09

Madeleine House 26/08/09

Madeleine House 24/06/09

Madeleine House 24/08/06

Madeleine House 23/11/05

Madeleine House 05/05/05

Madeleine House 10/12/04

Madeleine House 09/06/04

Madeleine House 20/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Madeleine House 60 Manor Road Stechford Birmingham West Midlands B33 8EJ Lead Inspector Amanda Lyndon Key Unannounced Inspection 11th July 2007 09:45 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 Madeleine House DS0000016912.V341281.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. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Madeleine House Address 60 Manor Road Stechford Birmingham West Midlands B33 8EJ 0121 786 1479 0121 785 0621 Joanne.shaw@anchor.org.uk www.anchor.org.uk Anchor Trust 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) Mrs Joanne Shaw Care Home 41 Category(ies) of Dementia - over 65 years of age (10), Learning registration, with number disability over 65 years of age (41), Old age, not of places falling within any other category (41), Physical disability over 65 years of age (41) Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: currently under review 1. Minimum staffing levels to be maintained to a minimum of 4 care staff throughout the day and 2 care staff overnight, which is to be increased with any increase in resident`s dependency. This is to be in addition to the Manager, Deputy Manager and Ancillary Staff. Plus an Activities Co-Ordinator for at least 20 hours per week. The registered person may provide personal care (excluding nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories:old age not falling within any other category, OP, 41; physical disability - over 65 years of age, PD(E), 41; learning disability - over 65 years of age, LD(E), 41; dementia - over 65 years of age, DE(E), 10. The maximum number of service users to be accommodated is 41. 2. 3. Date of last inspection 24th August 2006 Brief Description of the Service: Madeleine House is registered to provide residential care for up to 41 residents who are over 65 years of age and require assistance for reason of old age and physical disability. This includes ten residents who can be accommodated for reasons of dementia care. The Home is owned and managed by Anchor Trust. It is a modern two storey building set back off the road in its own grounds with adequate off road parking to the front of the building. It is well maintained internally and externally and is run as one unit. There is a garden that is suitable for wheel chair users to the rear of the property and access can be gained from the dining room patio doors via a ramp. The Home is well located with easy access to public transport, shops, a public house and swimming baths. Accommodation is provided in 41 single flats, all having en-suite facilities that consist of a toilet and hand wash basin and a small kitchen area including a fridge. There is a call bell facility in each flat in order for residents to summon assistance from staff 24 hours a day. Communal space comprises of a lounge/dining room on the ground floor and a small quiet sitting room on the first floor. An attractive spacious conservatory has recently been built as an alternative sitting area for residents to enjoy. Madeleine House is a non smoking building however following assessment residents are permitted to smoke within their flats and in the garden. There is a passenger lift that gives access to all areas in the Home and there is Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 5 a range of equipment for moving and handling residents who may have decreased mobility. The physical environment of the Home is suitable for wheelchair users. A number of assisted bathrooms and shower rooms are strategically situated around the Home and these meet the needs of the residents living there. Staff are available to provide assistance with bathing as required. There are notice boards in key areas of the Home displaying forthcoming events and other information of interest to residents and their visitors. A copy of the last CSCI inspection report was available in the reception area of the Home for residents and visitors to refer to. The weekly fee to live at Madeleine House is £420 and this includes a top up fee of £30. Items excluded from this fee include hairdressing, chiropody newspapers, magazines and toiletries. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the Home and their views of the service provided. This process considers the Care Home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Information obtained and used in the planning of this field work visit included Regulation 37 notification reports of any accidents or incidents involving people using the service and complaints received by CSCI since the last key visit. In addition, the Registered Manager had completed a self- assessment document, giving some information about the Home, residents and staff which was also taken into consideration. Prior to the visit seven completed questionnaires were returned to CSCI from residents, their families and Doctors and these included positive comments about the service provided at Madeleine House including: “Overall I am impressed by care given at Madeleine House” “They treat people well and with respect” “No areas require significant improvement” No negative comments were received. A random visit was undertaken at Madeleine House on 31 January 2007 in order to monitor the progress made since the previous key visit dated 24 August 2006. The outcome of this was that it was evident that the newly appointed Home Manager was keen to improve the standard of service provided however a number of requirements were made regarding care planning and delivery and the management of medication. Following this an inspection was undertaken by CSCI’s Pharmacist Inspector and further requirements were made. This information was also taken in to consideration when planning for this visit. The field work visit referred to in this report was undertaken over one day by one Inspector when there were thirty five residents living there. The Home was not aware that we were visiting. Information was gathered by speaking with eight residents, three visitors, the management team and three staff members. An additional method of obtaining information was “case tracking” two residents in order to establish their individual experiences of living in the Care Home by meeting and observing them, discussing their care with staff, looking at care files and focussing on the outcomes for these people. A partial tour of the Home relevant for these people was also undertaken. Tracking residents’ care helps us understand the experiences of people who use the service. No immediate requirements were made on the day of the visit. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 7 What the service does well: Prior to coming to stay at the Home prospective residents and their families are encouraged to sample what life would be like to live at the Home. One relative said “ We felt really happy when we viewed Madeleine House for the first time and now on the second visit we feel even better. The staff are very welcoming”. Any information of interest to residents can be made available in different formats for example large print, audio tape or in other languages so that everybody can access this information. Residents have access to a range of Health and Social Care Professionals and staff provide support to ensure that any instructions are carried out and this ensures that any health care needs are met. Residents are cared for in a respectful manner by staff working at the Home and this ensures that their self- esteem and dignity are maintained. The staff team have a good knowledge about residents’ individual care needs, and approach residents in an understanding and sensitive manner so that residents feel calm, confident and relaxed. Residents are able to exercise control over their daily lives and this promotes their independence and individuality. Residents are supported to form friendships with each other so that they can share their experiences with each other. One resident said “On a Monday we go to a church club together. We like it because we meet with different people”. Residents are supported to continue to practice their chosen religions and this ensures that their beliefs and individuality are respected. Visitors are made to feel welcome and a good rapport had built up between residents, staff and their visitors. One visitor said “All of the staff are really lovely and are friends to us. I have a meal with my Dad here and the food is really good”. There is a choice of wholesome meals which meet any dietary needs for reasons of health, taste, culture or religion. Complaints are investigated in an appropriate and timely manner so that people are confident that their views are listened to and the appropriate actions are taken. Residents are provided with a clean and homely internal living environment in which they are safe and secure and their privacy is respected. Residents are Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 8 encouraged to personalise their bedrooms to reflect their individual tastes, age, gender and culture so that they feel comfortable in their surroundings. one resident said “I am very satisfied with my flat. The Cleaner comes once a week and the staff make our beds every day”. Aids and adaptations are provided so that the independence, choice and dignity of residents are promoted whilst maintaining their safety. Regular maintenance checks of this equipment ensure that they are safe to use. Comprehensive checks are undertaken on all new staff before they start working at the Home so that residents are protected. Residents and staff are satisfied with the staffing levels so that there is an adequate number of staff on duty to support residents. One resident said “The staff come and check on me during the night”. Residents are invited to group meetings to discuss the services provided at the Home. One resident said “The residents’ meetings are very useful. They keep us occupied and tell us what is going on”. Service satisfaction questionnaires have been distributed to residents in order to obtain their views about the service provided. This is in order to monitor the quality of services provided and make improvements as necessary. Residents have the option of using the Home’s facility for the safekeeping of small amounts of money. What has improved since the last inspection? The statement of purpose and service user guides had been updated so that they contained up to date information about what it would be like to live at Madeleine House. Residents are involved in the planning of their care so that any preferences in respect of their daily lives are maintained whilst living at the Home. All residents are weighed regularly and extra calories are added to their diet if they are underweight. Residents receive their medication at the times that they require and any errors regarding this are identified quickly so that the appropriate actions can be taken. Staff have received training about this so that residents receive their medication as prescribed by their Doctor. All residents are offered the key for their flat and lockable storage facilities are provided in each flat for the safekeeping of valuable and private items. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 9 A “residents’ newsletter” is produced and this has proved to be very popular with residents. One resident said “I enjoy the newsletter. I have just done the quiz out of it”. Staff have undertaken training about the protection of vulnerable adults and this should protect residents from harm. Some areas of the Home had been redecorated and new dining furniture had been purchased so that residents can enjoy their meals in a comfortable and attractive setting. New letterboxes have been fitted to residents’ doors that comply with fire regulations. This is so residents can continue to receive their post in this way and the risk of fire spreading throughout the building is reduced. Inventories of residents’ personal belongings and valuables brought in to the Home are kept so that all items are accounted for. A hygienic system for the laundry of residents’ personal clothing and bed linen is in place. 50 of care staff have achieved a care qualification so that they should have the necessary skills and knowledge to provide a good standard of care. Residents and staff benefit from a stable management team and the Home is run in the best interests of the residents living there. One staff member said “The Manager is very good and has brought in changes here slowly, I could go to her for anything”. 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. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 10 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 Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 11 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): 1, 3, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission processes are thorough so that prospective residents know before admission that their care/support needs could be met at the Home. Prospective residents have enough information about the Home in order to make an informed decision about whether they would like to live there. EVIDENCE: The comprehensive service user guide and statement of purpose had been revised recently and was produced in a large print format. Copies of these were available in residents’ flats for them to refer to. These included information of interest to prospective and existing residents, for example, the services provided at the Home, additional charges incurred, the staffing structure and meal arrangements. This had been updated recently in line with new government legislation about smoking in Care Homes. Ten people with dementia care needs can be accommodated at Madeleine House and this was identified within the statement of purpose. This is to ensure that prospective Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 12 residents have enough information in order to make an informed decision about whether they would like to live there. The Registered Manager stated that this could be made available in other formats and languages on request so that all people could access this information. Prospective residents are encouraged to spend a day at the Home in order to sample what life would be like to live there. On the day of the visit two prospective residents were at the Home accompanied by their families. One relative said “ We felt really happy when we viewed Madeleine House for the first time and now on the second visit we feel even better. The staff are very welcoming”. Another visitor said “We didn’t have to make an appointment to view here, that tells you everything, we were welcome any time”. Either prior to, or during trial visits, senior staff undertake comprehensive pre admission assessments of prospective residents’ care needs in order to determine whether these could be met whilst living at the Home. These included information about their personal objectives and main aims of coming to stay at the Home so that the staff could begin to plan for their individual care needs. The Social Worker of one prospective resident came to visit during the trial visit so that a comprehensive social care assessment could be undertaken for this person. Intermediate care is not provided at Madeleine House however residents can come to stay there on a temporary basis. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 13 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): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health provision and care delivery are good promoting residents’ health, well– being and safety. Residents generally receive person centred care so that their individuality and personal preferences are maintained and residents receive their medicines as prescribed by their Doctors. EVIDENCE: Since the last visit improvements have been made regarding the care planning system used in order to strive towards all residents receiving person centred care. Staff are in the process of updating all care plans using new documentation supplied by the Provider. On admission, comprehensive assessments are undertaken of residents’ individual care needs and preferences regarding their daily lives and care plans are derived from this information. These included good detail of the specific support required by staff in order to meet residents’ needs and promote their independence and individuality. Residents and their families are involved in the writing and reviewing of care plans so that their preferred routines could be Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 14 maintained whilst living at the Home. Care plans sampled were reviewed thoroughly so that the information included was up to date. Short term care plans had not always been written in order to identify the support required by staff regarding some short term care needs. In addition care plans had not always been written to identify the support required by staff in order to reassure residents that may experience agitation and confusion. Staff, however had a good knowledge of “trigger factors” that may cause residents to become agitated and the support required regarding this. Good progress had been made regarding the development of personal risk assessments. Whilst these were comprehensive, some were found to be confusing and included information that was not required as no risk was identified for that person. Brief moving and handling risk assessments had been undertaken however these would be further developed following staff training in this area, (training was being undertaken on the day of the visit). There were inconsistencies regarding the content of daily reports. Some included good detail of the activities that residents had engaged in that day whilst others gave limited information and were repetitive. None of the residents currently living at the Home have sore skin however suitable equipment used for the prevention of this could be obtained via the district nursing team. A number of residents had sensory impairments and one resident who is registered blind expressed her satisfaction about the support provided to her regarding this and the services/equipment she is entitled to. Another resident confirmed that she had been assessed for a hearing aid and was currently waiting for this to be ready for collection. Residents have access to a range of health and social care professionals that visit the Home including social workers, opticians, chiropodists and dieticians. Residents have the option of retaining their own general practitioner on admission to the Home (if the GP is in agreement) Residents appeared to be well supported to maintain their personal hygiene and choose clothing, jewellery and make up appropriate for their age, gender and culture. One resident said “I have a shower twice a week with the help of a carer. It is lovely having a shower, twice a week is enough for me”. Since the last visit vast improvements have been made regarding the safe management of medication, including prescription creams and the systems in place for the receiving, administration and disposal of medicines were robust. All staff currently responsible for the administration of medication had undertaken appropriate training in this area. Medication administration charts (MAR) were well maintained and medications were accurately recorded. An exception to this was the administration instructions for one course of eye drops that stated “give as directed”. This may result in administration errors as no specific guidelines for administration were recorded. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 15 One resident had chosen to self administer her own medication and a care plan had been written about the support required by staff in this area. Compliance checks are undertaken to ensure that the medication is administered correctly and a suitable lockable facility is provided for the safe storage of this. Since the last visit there had been two incidents of concern regarding the management of medication and it was pleasing that work practices have been reviewed as a result of these. Medication charts are now audited on a regular basis and stock balances of medication sampled during the visit were correct. In order to detect any prescribing or dispensing errors, two staff members check all medication into the Home and it is recommended that the signatures of both of these people are obtained as confirmation of medicines received. Residents have the option of having a key for their flats which can be overridden by staff in the event of an emergency. A number of residents had chosen not to have the key and a record of this was kept. Lockable storage facilities are now provided in each flat for the safekeeping of medication and private and valuable items. Residents’ post is delivered to their flats via their own letterboxes. The preferred term of address is recorded within care plans and staff were observed greeting residents by these. A payphone is available for residents’ use and in addition a number of residents have chosen to have a telephone line in their flats so that they can make and receive calls in private. Confidential records relating to residents (activity records) had been taken off the premises and these must be kept at the Home in order to ensure that residents’ confidentiality is maintained. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 16 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): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities on offer meet the needs, abilities and expectations of residents so that their interests can be maintained. Residents exercise control over their daily lives and staff respect their personal preferences in respect of this so that their independence and individuality are maintained. Residents are supported to lead independent and fulfilling lives. Residents have a choice of healthy meals that meet any special dietary requirements for reasons of health, taste and cultural/religious preferences. EVIDENCE: An activities co ordinator is employed at the Home, dedicated to providing opportunities for residents to pursue their leisure interests and positive comments were received about her work performance. One resident said “ She is very good. She puts herself out for us”. Activities on offer reflected the age and interests of residents and included activities both “in house” and in the local community including craft sessions, Great Britain Day celebrations, karaoke and memory games. One to one sessions are available for residents unable to participate in group activities and plans are in place for a number of residents to go to Wales. A summer fete had been held recently and library Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 17 books were available. A number of residents choose to have a daily newspaper delivered and a hairdresser visits the Home each week. The activity records were not available at the Home on the day of the visit so these were not sampled on this occasion. There was an activity board displaying forthcoming events so that residents could choose which activities they wanted to take part in. Posters were produced in a large print format so that residents with poor eyesight had access to this information. A “residents’ newsletter” had recently been produced and was popular with residents met during the visit. This included a “This Is Your Life” feature on individual residents who agreed to share their life experiences with other residents. Copies of the minutes of residents’ meetings were included in the newsletter and there was a section titled “What Do You Think?”. This provided residents with the opportunity to put forward their suggestions for improvements regarding the services provided at the Home. Other features included poetry written by a resident and prize quizzes so that there was information of interest for all residents. One resident said “I enjoy the newsletter. I have just done the quiz out of it”. A number of residents frequently go out with their families and friends and this ensures that they maintain contact with those people important to them. One resident said “I am off to my daughters today to see my grandchildren. I have my dinner and tea there”. Following assessment some residents choose to go outside of the Home on their own to local shops or to attend local day centres so that they have opportunities to meet with people of similar ages outside of the Home. A number of residents are registered with the “Ring and Ride” so that they can access community facilities. It was evident that friendships had formed between residents living at the Home and a number of residents chose to do activities together. One resident said “On a Monday we go to a church club together. We like it because we meet with different people”. Opportunities for residents to continue to practice their chosen religions were provided including Holy Communion and a monthly church service being held at the Home. A number of residents choose to watch the Sunday Service on the television. There is an open visiting policy and it was evident that a good rapport had built up between visitors and staff. A relatives’ meeting was planned for the near future and this ensures that relatives are involved in decisions about the services provided at the Home and any issues raised can be addressed promptly. Topics to be discussed include relatives’ ideas for activities and the suggestion of a “relatives’ forum” to be developed. Residents are able to meet with their visitors in private should they choose. One visitor said “All of the staff are really lovely and are friends to us. I have a meal with my Dad here and the food is really good”. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 18 There are no rigid rules or routines at the Home and residents confirmed that they were able to go to bed and wake up at the times that they preferred. One staff member said “If residents don’t want to go to bed at a certain time then that’s fine”. Residents who are able, are encouraged to keep their own flat clean and tidy as this promotes their independence. Residents had the choice of being served their meals where they chose and a number of residents had chosen to have their breakfast in their flats. A hot trolley had recently been obtained to ensure that residents received their breakfasts at the correct temperature and this was due to be serviced prior to being used to ensure that it was safe to use. Menus identified that there were a variety of nutritious home made meals provided at the Home and suggestions for menu choices were discussed during residents’ meetings. There was evidence that any suggestions put forward by residents were added on to the menu. Special diets could be arranged for reasons of health, taste or cultural/religious preferences and diabetic, soft and weight reducing diets were currently being prepared. “Themed Meals” are arranged so that residents can experience different tastes. Residents are weighed and nutritional assessments are undertaken for each resident in order to identify any abnormalities regarding this. Extra calories are added to meals prepared for residents who are deemed to be in need of extra nourishment. Cooked breakfasts are prepared twice a week and both hot and cold food options are available at teatime. A snack meal is available before bed and during the night so that residents are not hungry. Residents confirmed that they are offered a choice of meals and the choices are identified on suitable menus available on the dining tables. The main meal choices on the day of the visit were roast gammon or red salmon with parsley sauce and alternatives to this were also available. There was a variety of desserts available for residents to choose. Assorted sandwiches were available at tea- time and it is recommended that the choice of sandwich fillings are identified on the menu so that residents can choose which sandwiches they would prefer. Staff were assisting residents during lunch time in a sensitive manner and time was taken to explain to them what the menu choices of the day were so that residents could choose what they wanted to eat. Plate guards and adapted cutlery were available in order to promote residents’ independence and dignity at mealtimes however there was no need for these at the current time. Dining tables were laid attractively with flowers and salt/pepper and cold drinks were available for residents to serve their own as able. One resident said “We have all got different tastes but the food is good”. A “comments book” was available in the dining room and this contained predominantly positive comments about the meals provided. Negative comments recorded within the book were acted on in a constructive manner. The Chef/Manager was very enthusiastic within his job role and had recently attended a “People’s Voice” Conference. Within this role he ensures that all Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 19 new workers have training about the importance of residents’ nutrition and supporting them in an appropriate manner at mealtimes. Remedial action had been undertaken following the most recent Environmental Health inspection so that food is prepared in a hygienic environment and staff had received training in this area. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 20 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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their visitors are confidant that their views are listened to any issues raised are dealt with in an appropriate and timely manner. The revised systems in place for adult protection should protect residents from harm. EVIDENCE: Since the last key visit the Home had received two complaints about the services provided regarding medication practices and the opportunities available for residents to smoke within the Home. Work practices had been reviewed in response to these to the satisfaction of the complainants. A number of compliments and “thank you” cards about the services provided at the Home were on display. A comprehensive complaints procedure was on display in a prominent position of the Home for residents and staff to refer to. In addition leaflets detailing how to make a complaint were available in the Home. It was of concern that a period of four weeks had lapsed until staff reported an incident of an adult protection nature to the management team. Following this time the appropriate authorities were informed so that an investigation could be undertaken. The Provider was also concerned that staff had failed to report the incident and further training in this area was arranged without delay. It must be noted that this occurred prior to the current Manager coming into post Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 21 at the Home and communications/incident reporting procedures have now improved. Staff met during the visit confirmed that they had undertaken recent training about their roles and responsibilities regarding the protection of vulnerable adults. In addition the management team had recently followed appropriate adult protection procedures following an incident of a possible adult protection nature involving two residents. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 22 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): 19, 20, 21, 22, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a homely, comfortable and clean living environment in which their privacy and safety is maintained. Further measures are however required to improve the security of the garden in order to safeguard vulnerable residents. Aids and adaptations provided are fit for the purpose and need of residents. EVIDENCE: The front of the Home was attractive and welcoming with flower pots and hanging baskets on display. The reception area was inviting and there was a fish tank as a focal point and a comfortable settee for residents’ use. A rolling programme of redecoration was in place. Some improvements had been made regarding the physical environment of the Home in order to improve the quality of life for residents with dementia. This includes colour coded corridors and residents’ names and photographs on flat doors. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 23 There is a large dining room/communal lounge and conservatory so that residents have a choice of where to spend their time. The conservatory overlooks the well maintained garden so that residents have a lovely view to look at when relaxing in this area and a ceiling fan and window blinds are provided so that it should not get too hot in this area. The lounge was very homely, was furnished to a good standard and had a feature fireplace. Chairs had been arranged within the lounge in order to promote social interactions between residents. A loop system has been installed in the lounge to enable hearing impaired residents with hearing aids to hear better. Appropriate music was being played in the lounge on the day of the visit. New suitable dining furniture had recently been purchased and residents were being consulted about the choice of table linen to be purchased. Residents were also in the process of choosing new lounge furniture and fabric and colour swatches were available in the Home. The carpet in the main lounge was damaged from cigarette burns and should be replaced so that residents are provided with a homely area in which to spend their time. Smoking is no longer permitted in this area and residents that choose to smoke can do so in their flats following assessment or in the garden. There was a leak from the ceiling in the lounge and the roof was in the process of being repaired. Residents have a choice of assisted bathing and shower facilities and staff are available to provide support in these areas, ensuring that residents’ privacy is maintained. Other aids and adaptations provided include mechanical hoisting equipment, handrails in corridors and near to toilets, walking frames and a passenger lift to all floors of the Home. Residents’ flats were spacious and decorated to a good standard. Each flat includes a small kitchen unit so that residents can prepare their own light snacks and hot drinks at the times that they choose. Residents are encouraged to furnish their flats with their own belongings so that they are comfortable within their surroundings. Call bell facilities are provided in all flats so that residents can summon assistance from staff. Pendant style call bell equipment had been purchased for a number of residents deemed to be at risk of falling or had physical impairments. New letterboxes have been fitted to residents’ doors that comply with fire regulations. This is so residents can continue to receive their post in this way and the risk of fire spreading throughout the building is reduced. Residents access the garden through the dining room and conservatory via a ramp so that it is suitable for wheelchair users. Plans are in place for this area to be made secure so that it is safe for vulnerable residents to use and there is garden furniture available for residents to use. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 24 There are hygienic systems in place for the laundry of residents’ personal clothing and bed linen. Staff are available to assist residents if they choose to do their own laundry. The Home was clean and fresh and one resident said “I am very satisfied with my flat. The Cleaner comes once a week and the staff make our beds every day”. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 25 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): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive support from an adequate number of appropriately recruited staff. Refresher training is required in some areas so that staff provide support to residents in a competent and safe manner. EVIDENCE: The staffing levels are regularly reviewed based on the dependencies of residents living at the Home to ensure that there is an adequate number of staff on duty to support residents. The Registered Manager stated that she was satisfied with the current staffing levels. One staff member said “The staffing levels are ok but it can be hard when we are helping people into bed”. No negative comments were received from residents regarding this. One resident said “The staff come and check on me during the night”. The Registered Manager stated that they had recently recruited a number of staff on an “as required” basis to cover periods of staff sickness, holidays and maternity leave”. Agency staff are rarely used and this ensures continuity of care for residents. Housekeeping and catering staff are provided so that residents are supported in all aspects of their daily lives. Staff recruitment files sampled included all information required by regulations and all staff were deemed to be safe to work with vulnerable people prior to Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 26 commencing employment at the Home. An exception to this was that a reference from the most recent employer of a new worker was not available on file however during the visit the administrator confirmed with the referee that this had been received prior to the person commencing employment at the Home. New workers undertake comprehensive induction training so that they should have the necessary skills and knowledge to work in a competent manner. Staff had undertaken recent training so that they should have the necessary skills and knowledge to provide a good standard of care. This includes training about dementia care and care planning. The staff training matrix identified that a number of staff required refresher training in mandatory areas for example, fire safety, health and safety and first aid (the latter mainly being night workers). This was due to “Trainers” leaving employment at the Home and staff members were currently being trained to undertake these roles. Fire safety training is planned and forthcoming training dates were on display. Some staff met during the visit stated that they had undertaken recent training about fire safety and moving and handling in conjunction with staff at another Home owned by the Provider in the absence of “Trainers” being available at Madeleine House. A fire drill had been undertaken recently so that staff should have the appropriate knowledge of how to act safely in the event of a fire. 50 of care staff had achieved the NVQ level 2 in care qualification so that they should have the appropriate knowledge to provide a good standard of care for residents. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 27 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): 31, 32, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed Home and is run in the best interests of the residents living there. Systems in place for quality monitoring and resident consultation are good and residents are confident that their views are acted upon. Arrangements for health and safety are good. EVIDENCE: The Registered Manager has been in post for ten months and has successfully registered with CSCI. She has worked within the care service since 1986 and has achieved the Registered Managers’ Award in order to acquire the necessary skills to lead the staff team. It was evident that since her appointment improvements had been made regarding the care and services provided at the Home. In particular excellent progress had been made Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 28 regarding the systems in place for resident consultation and positive comments were received about her management style. One staff member said “The Manager is very good and has brought in changes here slowly, I could go to her for anything”. The Registered Manager is supported by a Deputy Manager and both are available at weekends on a rota basis so that residents, staff and visitors are supported at that time. One resident said “The Managers come round and say “hello”. Residents’ meetings are held regularly so that residents had the opportunity to put forward their views about the services provided at the Home. Topics discussed include food options and activities arranged. There was a voting slip for residents to vote on the dining table linen to be purchased and residents were consulted about how to spend a grant given to the Home by the government. There was evidence that these suggestions were acted upon for the benefit of residents. One resident said “The residents’ meetings are very useful. They keep us occupied and tell us what is going on”. Staff meetings are held regularly so that there are opportunities to discuss residents’ care, training opportunities and improvements required regarding work practices in order to ensure better outcomes for residents. Quality monitoring visits are undertaken by External Senior Managers on a regular basis and the reports of these were available. These included the views of residents met during the visits and any action taken to address any issues raised. Service satisfaction questionnaires are distributed to residents, visitors and staff in order to seek their views about the care and support provided at the Home. A report had recently been produced based on the findings of these and mainly positive feedback was obtained. The majority of relatives stated that they were not invited to take part in group meetings, therefore a date for a relatives’ meeting was on display. The report of the findings had been taken by a visitor therefore the Registered Manager stated that she would replace this so that residents and their visitors could read the report. In addition a formal quality assurance survey had been undertaken by an external source and the report based on the findings of this was on display. This included comments made by residents living at the Home. As previously agreed with CSCI, residents’ personal allowances are paid into one general bank account and individual electronic and paper records of this were well maintained and audited regularly safeguarding residents who choose to use this facility. There had been no changes to this system since the last visit to the Home. Inventories of residents’ personal belongings and valuables brought in to the Home are now kept so that audits of residents’ belongings can be undertaken. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 29 Regular checks of equipment within the Home are undertaken so that they are safe to use. Accident records were well maintained and audited regularly so that any trends could be identified and measures put in place to reduce the risk of further accidents of a similar nature. There was evidence that the appropriate medical advice is sought promptly following accidents involving residents as required. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 30 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 3 x 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 3 3 x 3 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 3 3 3 x 3 x x 3 Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 31 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 OP7 Regulation 15(1) Requirement Arrangements must be made to ensure that all staff are aware of the support required in order to meet residents’ short term care needs. Residents’ confidentiality must be maintained at all times. The garden must be fit for the purpose and needs of all residents living at the Home. (Timescale of 15/09/06 and 15/04/07 not met). Arrangements must be made for all staff to undertake refresher training in mandatory areas so that they should have the necessary skills and knowledge to work in a safe and competent manner. Timescale for action 15/09/07 2 3 OP10 OP19 12(4)(a) 13(4) 15/08/07 01/10/07 4 OP30 13(4)(5) 18(1) 01/11/07 Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 32 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 4 Refer to Standard OP7 OP7 OP9 OP20 Good Practice Recommendations Each resident should have a set of personal risk assessments relevant to their individual care needs so that they can lead fulfilling and safe lives. Daily reports should reflect the care and support provided to residents in order to form part of the care reviewing process. Suitable arrangements should be made to confirm that two staff members check all medicines in to the Home. The damaged carpet in the lounge area should be replaced. Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Madeleine House DS0000016912.V341281.R01.S.doc Version 5.2 Page 34 - 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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