CARE HOMES FOR OLDER PEOPLE
Madeleine House 60 Manor Road Stechford Birmingham West Midlands B33 6EJ Lead Inspector
Ann Farrell Unannounced Inspection 23rd November 2005 08.00 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 Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 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.V267278.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Madeleine House Address 60 Manor Road Stechford Birmingham West Midlands B33 6EJ 0121 786 1479 0121 785 0621 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) Anchor Trust Matthew Bell Care Home 41 Category(ies) of Dementia - over 65 years of age (5), 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.V267278.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. Learning Disability over 65 years of age (41). Old age, not falling within any other category (41). Physical disability over 65 years of age (41). Dementia over 65 years of age (5). 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 additon to the Manager, Deputy Manager and Ancilliary Staff. Plus an Activities CoOrdinator for at least 20 hours per week. 5th May 2005 Date of last inspection Brief Description of the Service: Madeline House provides accommodation for 41 residents who are over 65 years of age and require assistance for reason of old age and physical disability. 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 parking to the front of the building. The home is well maintained internally and externally. There is a garden to the rear of the property and access can be gained from the dining room patio doors and a ramp. Accommodation is provided in 41 single bed-sitting rooms. All rooms have ensuite facilities that consist of a toilet and wash hand basin and in addition there is a small kitchen area in each flat with a fridge. Communal space comprises of a lounge/dining room on the ground floor and a small quiet sitting room on the first floor. There is a passenger lift that gives access to all areas in the home and they have a range of equipment for moving and handling residents. A number of bathrooms and shower rooms are strategically situated around the home. The home is well placed with easy access to public transport, shops, public house and swimming baths. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis over a full day commencing at 8am on 23rd November 2005. The registered manager was present for the duration of the inspection. During the inspection process the inspector sampled residents files and case tracking was undertaking in addition to inspection of other documentation. The manager, three members of staff, approximately eight residents and two relatives were spoken to. Residents stated they enjoyed living in the home and the staff were good from the manager to the housekeeping staff. What the service does well:
The home is friendly, relaxed and welcoming. The manager’s office is situated in the main reception area enabling visitor’s easy access to discuss any issues or concerns. The relatives visiting stated they were pleased with the home and found staff helpful. “ They look after them well”. They felt able to speak to the managers if they had any concerns. The staff stated they were happy working in the home and worked as a team. They found the managers approachable and supportive. The deputy manager works with care staff on the floor and they are prompt in noting changes in resident’s conditions. An activities co-ordinator is employed and she arranges a range of activities for residents. She has recently joined the National Association of Provider of Activities for Older People. Staff are friendly and welcoming and there was noted to be a good rapport and relationships between staff and residents. Routines are fairly flexible and there is no restriction on visiting. The home is clean and well maintained providing a safe environment. All flats are single with en-suite facilities consisting of toilet and wash hand basin plus kitchen facilities. In addition, there is a range of shower or bathing facilities on-each floor providing a choice for residents There are good procedures in respect of residents laundering, where it is undertaken individually. A quality assurance process is in the home and they scored highly and received very positive feedback from residents and relatives. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 6 The home has an information pack available for prospective residents enabling them to make an informed decision about moving into the home. There has been an improvement in recording of assessments providing a record of residents needs. EVIDENCE: The home admits residents primarily for long term care, but also has one room for respite care. Information is available for prospective residents and their representatives in the form of a welcome pack. At the time of visiting the inspector spoke to a resident who had recently moved into the home and stated, “ I think it’s more than good”. The home liaises with social workers who provide written assessments/care plans for residents who wish to enter the home. Staff also invite prospective residents to the home enabling them to view the facilities, meet staff and other residents. At this stage the home is able to undertake an initial assessment to determine if they are able to meet residents needs. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 9 Following admission to the home a more comprehensive assessment is undertaken and an individual lifestyle agreement (ILA) is drawn up outlining residents needs and how they should be met by staff. There is a trial period of one month when a review is held with the resident, staff and family. On inspection of a sample of records pre admission assessments and admission assessments had been undertaken. There was noted to be an improvement in the records providing a good range of information. The home is now registered to provide care to a small number of residents with dementia and approximately half of the staff have undertaken training in this area. The manager has also stated previously that the deputy manager and himself are hoping to undertake some more in depth training. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10 The home has arrangements in place to meet resident’s health care needs. Further development of care plans is required to ensure that all staff are aware of the action required to meet their needs and ensure consistency. The change in medication system has lead to some improvements, but further work is required to ensure all residents receive the medication prescribed to them. EVIDENCE: The home draws up an individual lifestyle agreement (ILA) for each resident following admission to the home outlining how the resident’s needs are to be met by staff. On inspection of a sample of records they were found to be vague in areas, lacking detail and all needs had not been included in the plan of care. Daily records were basic and included statements such as “ seems fine”. Manual handling assessments had been completed, but there was little evidence of any other risk assessments and where some risks had been identified there was no indication of the action to reduce the risk. The medication system has changed and it was noted that the medication in blistered packs were of a good standard.
Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 11 However, audits in respect of medication in boxes or bottles were not accurate and the administration of creams was not recorded. It was also noted that risk assessments had not been undertaken for residents who administer their own medication. Also it was noted that a member of staff had decanted medication into a medicine pot, which was left in the trolley. This is not appropriate practice. The temperature of the room where medication is stored was above 25 degrees and the fridge temperature was outside the recommended levels. These must be monitored regularly and if they continue to be outside the correct range appropriate action must be taken. All staff have completed medication training and the manager was advised that audits of staff undertaking medication should be undertaken. On discussion with resident’s they stated they were happy living in the home, and found the staff very good. One resident stated “ the home is getting better and better”. All flats have locks to doors and residents confirmed they had keys to their doors. The home was in the process of fitting lockable facilities in flats. Some residents have had a telephone installed in their own room and a pay phone is available on the ground floor, which has been partially partitioned. In addition, there is a telephone available in the small lounge area on the first floor if further privacy is required. Staff were observed to interact with residents and treated them with respect. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 There is a relaxed atmosphere in the home with flexible visiting arrangements. Residents are able to make choices about daily living activities and an activities co-ordinator is employed, who organises a range of leisure activities to suit residents. EVIDENCE: The home employs an activities co-ordinator who works twenty hours per week and she is responsible for organising a programme of activities. On discussion with the activity co-ordinator she stated that she is in the process of undertaking assessments with residents in order to obtain information about past interests and hobbies. It was also stated that her hours will be increased next year and it is hoped to involve other staff with activities. In addition, she is hoping to introduce meetings with relatives. There are regular exercise sessions in the home. There is a karaoke machine, television and music centre in the lounge. They have bingo sessions, visiting entertainers, shopping trips and one to one sessions. There has been a trip to Lichfield a Café Royal night recently and trips are planned for Cadbury World and a local garden centre. On the day of inspection Thornton’s Chocolate Company and a skin care organisation were displaying products for sale and the staff provided sherry and mince pies for residents and visitors.
Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 13 They celebrate events such as Easter; Christmas, New Year, birthdays and it was stated they hope to celebrate a 100th birthday later in the year. One of the residents goes out to a day centre three times a week and others go out with family on a regular basis. The hairdresser visits the home on a regular basis. Ministers of various denominations visit and a service is held in the home each month. Visiting is flexible and residents have a choice of areas to receive visitors, which was evidenced at the time of inspection from discussion with a relative. Residents take their own furniture into the home enabling them to create a home from home environment and can handle their own finances if they wish, although assistance is available in the home if required. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Feedback indicates that the home is responsive to concerns raised. However, records were not available to demonstrate robustness of the procedures and staff lacked knowledge of some of the procedures for the protection of residents. EVIDENCE: The home has a complaints procedure displayed on the notice board. On discussion with residents they stated they had no complaints and it was noted that the complaints procedure had been discussed at a recent residents meeting. The home receives very few complaints and had not received any since the time of the last inspection. On discussion with some staff there was a lack of clarity about the recording of complaints and the action to take in the event of an allegation of abuse. This was discussed with the manager and action will need to be taken to address these areas. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The standard of décor and furnishings in the home is good, providing residents with a pleasant and homely environment to live. EVIDENCE: The lounge/dining room, one flat and the new bathroom were only inspected at this time. They were clean and well maintained providing a homely environment. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 The home maintains satisfactory staffing levels and staff morale was good. The recruitment procedures require further development to demonstrate robustness. EVIDENCE: The staffing rotas indicated that the manager and assistant manager are on duty plus one senior carer and three care staff during the day. The manager stated that he has made plans for an increase in staffing levels in the New Year. A small number of staff files were examined and it was noted that only one reference was available and there was no proof of identity on another file. Almost 50 of staff are trained to NVQ level 2 and a further five staff are currently undertaking the training. There has also been a range of training in the home since the time os the last inspection. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 The manager, who is supported by the senior team, provides an open, positive approach. The home is managed in the interests of the residents and their health, safety and welfare is protected. EVIDENCE: The registered manager has completed the management element of the Registered Managers Award and is to undertake the care modules soon. On discussion with staff they stated the managers were approachable and staff felt they could discuss any issues or concerns with them. They felt there was a good working atmosphere and felt part of a team. There was evidence that residents are consulted about aspects of the home through meetings and on discussion with a number of residents they stated they were happy, one stated “ The home gets better and better ”. There has been some improvement in respect of formal staff supervision, but it is not consistently undertaken six times per year.
Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 18 Records in respect of outstanding maintenance issues were followed up. The manager stated that the issues in respect of the electrical wiring had been addressed, but there was no evidence available to demonstrate this. The manager must ensure that copies of such documents are retained in the home. The record of weekly fire tests and monthly emergency lighting indicated that these had not been undertaken are required. The manager stated that he has made plans to have some doors to flats linked into the fire alarm system in the New Year, as some residents need to have them open when they are in their flat. On inspection of the accident book it was noted that the Commission had not been informed as required under regulation 37. There has been a range of staff training in the home since the last inspection including infection control; management of continence, fire prevention, manual handling and first aid is being arranged for January. The home has a quality assurance system in place and have received very positive feedback from the organisation undertaking the accreditation. One company analysed questionnaires from residents and relatives and the home received very positive feedback scoring above the mean for all 37 attributes measured. The home handles money on behalf of residents and a secure facility is available. The system appears robust and records were found to be of a satisfactory standard. Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X X 2 Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 20 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 Requirement The registered person must ensure all care plans are fully completed and set out in detail the action to be taken by staff to meet resident’s needs. They must be reviewed on a monthly basis and where there are any changes. Timescale of November 2003 not met. The registered person must ensure; • The correct administration and recording of all medication. Timescale of November 2003 not met Ensure the administration of creams is recorded. Where variable doses are prescribed the amount administered must be recorded. Timescale of 25/5/05 not met. The drug fridge temperature is maintained between 2 and 8 degrees. The room where medication is stored must be maintained at 25 degrees.
Version 5.0 Page 21 Timescale for action 30/01/06 2. OP9 13(2) 30/11/05 • • • • Madeleine House DS0000016912.V267278.R01.S.doc 3. OP14 17(2)(4) 4. OP16 22 5. OP18 13(6) 6. OP29 19 7. OP36 18(2) 8. OP38 23(4)(c) 9. OP38 13(4) All residents who selfadminister medication must have a risk assessment undertaken. • Medication must not be left in medicine pots. The home must maintain an up to date list of all furnishings brought into the home by residents. Ensure the residents or their representative sign the record. Timescale of June 2004 not met. The registered person must ensure there is an appropriate system in the home where all complaints can be recorded and all staff are aware of it. The registered person must ensure all staff are aware of the local guidance for responding to any allegations of abuse. Timescale of June 2004 not met. The registered person must ensure evidence of staff identity such as birth certificate, marriage certificate, passport are available on all staff files and two written references are obtained. Timescale of 30/5/05 not met. The registered person must ensure there are systems in place for staff to be supervised at least six times per year. Timescale of 30/6/05 not met. The registered person must ensure the fire points are checked weekly, the emergency lighting is checked at least once a month and records are retained in the home. Timescale of June 2004 not met. The registered person must provide evidence to indicate the issues in respect of the electrical wiring system have been addressed. (The manager states the work has been completed,
DS0000016912.V267278.R01.S.doc • 15/12/05 30/12/05 30/12/05 30/12/05 30/12/05 30/12/05 30/12/05 Madeleine House Version 5.0 Page 22 10 OP38 37 but evidence is not available due to changes in administration.) Timescale of November 2003 not met. The registered person must inform the Commission of any accident/incident affecting the well being of residents. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP32 Good Practice Recommendations It is recommended that the registered manager introduce auditing/monitoring systems of various aspects to ensure all areas are being addressed Madeleine House DS0000016912.V267278.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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