Inspection on 24/08/06 for Madeleine House

This inspection was carried out on 24th August 2006.

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 11/07/07

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 6EJ Lead Inspector Amanda Lyndon Key Unannounced Inspection 24th August 2006 09:55 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.V308423.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.V308423.R01.S.doc Version 5.2 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 Vacant Janet Bennett (Acting Manager) 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.V308423.R01.S.doc Version 5.2 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 residents’ 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. 23rd November 2005 Date of last inspection Brief Description of the Service: Madeleine House provides accommodation for 41 residents who are over 65 years of age and require assistance for reason of old age and physical disability. Five residents 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 parking to the front of the building. The home is well maintained internally and externally. 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 and 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 wash hand basin and a small kitchen area including a fridge. There is a call bell facility in each flat in order for residents to summons 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. Smoking is permitted under staff supervision if required within resident’s flats and in the garden areas of the Home. There is a passenger lift that gives access to all areas in the Home and there is Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 5 a range of equipment for moving and handling residents who may have decreased mobility. A number of 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 £400 and this includes a “top up” fee of £30. Additional charges are made for hairdressing, chiropody newspapers, magazines and toiletries. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects the findings of a one day unannounced fieldwork visit undertaken by one Inspector when there were forty-one residents living at the Home. Information was gathered by speaking with residents and staff, case tracking, examining care, medication and health and safety records and observing the staff perform their duties. A tour of the Home was undertaken. The Inspector was assisted throughout the visit by the Acting Manager, the recently appointed Deputy Manager and the Administrator. A new Manager was due to commence employment at the Home in September 2006. Prior to the visit the previous Registered Manager had completed a pre inspection questionnaire and had returned it to CSCI, giving some information about the Home, residents and staff which was taken into consideration. In general positive comments were received from residents during the fieldwork visit about the service provided at Madeleine House. One resident said, “You will find it hard to beat this place”. What the service does well: Residents are well supported by the care staff to meet their health, welfare and personal care needs and are cared for in a respectful manner by staff working at the Home. Residents are involved in the agreeing and reviewing of their care plans ensuring that they have control over how their care needs are met. One resident said, “my care plan speaks volumes and we have a review of it every six months”. Another resident said, “The staff arrange appointments with my doctor for me”. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. There is a wide variety of activities on offer for the residents to participate in and this ensures that they are socially and mentally stimulated. One resident said, “ We all get on well here, the company is the most important thing”. One resident said, “I let the staff know when I am going out”. Another resident said, “I enjoy walking around the garden and I venture to the shops. I go in a taxi to my family’s house”. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 7 Residents are supported by the staff to maintain contacts with their friends and family and visitors are made to feel welcome at the Home and this ensures that residents feel comfortable within their home environment. One resident said, “ My family are made to feel welcome here when they come”. Residents receive a choice of wholesome meals which meet any dietary needs for reasons of health, religion, culture or personal tastes. Residents are provided with an attractive, homely and clean environment in which to live. Residents are encouraged to personalise their bedrooms in order for them to feel safe and secure in their surroundings and to reflect their individual tastes. Aids and adaptations provided ensure that residents’ daily living needs are met. One resident said, “My flat is very homely. The staff respect my privacy and don’t go into my flat unless invited”. Another resident said, “The cleaners clean our flats to an acceptable level”. Staff employed at the Home have received training to ensure that they perform within their job roles in a competent manner. The Home does not use agency staff and this ensures continuity of care. One resident said, “The staff are kind and attentive here”. There is a comprehensive complaints procedure and a “comments/suggestions book” is available to residents and visitors should they need to make a complaint. Residents are invited to regular meetings to discuss the service provided at the Home and to put forward any suggestions for improvements. One resident said, “I would go to the office if I had to complain, but I haven’t had to”. Another resident said, “I go to the meetings, they are useful. The Home does their best to listen to our suggestions”. Senior External Managers visit the Home regularly to monitor the standard of service provided at Madeleine House. There is a robust system for the management of residents’ personal allowances should the resident choose for the Home to hold this on their behalf. What has improved since the last inspection? Risk assessments are now available for residents who choose to self administer their own medication ensuring that they do so in a safe manner whilst maintaining their independence. A spacious and well lit conservatory has been built containing good quality comfortable furniture and this gives residents a choice of sitting areas in the Home. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 8 Staff have now received training about the protection of vulnerable adults in order to safeguard residents. Staff recruitment procedures are now robust and this safeguards residents. 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.V308423.R01.S.doc Version 5.2 Page 9 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.V308423.R01.S.doc Version 5.2 Page 10 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): 1, 3, 4 Quality in this outcome area is poor. This judgement was made using available evidence including a visit to this service. Prospective residents are invited to spend a day at the Home enabling them to sample what life would be like to live there in order to make an informed decision about whether they would like to live there. However, other pre admission assessment procedures were inadequate and this had resulted in inappropriate trial visits and some residents’ individual care needs not being met whilst living at Madeleine House. A number of residents living at the Home had additional mental health needs and the current strategies in place to meet these needs were ineffective at times which has had a negative impact on the well being of these and other residents living at the Home. EVIDENCE: Comprehensive statement of purpose and service user guides were available in the reception area of the Home and these provided prospective residents and their families with good detail of the services provided at Madeleine House. These required minor adjusting to reflect the current staffing details and the revised policy on smoking within the Home. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 11 Both documents were available in a large print format for people with poor eyesight. One resident said “ You will find it hard to beat this place” Prospective residents are invited to spend time at the Home and have a meal in order to sample what life would be like to live there. Pre admission assessments are undertaken for all prospective residents prior to coming to live at the Home. However the system for this was inadequate at times, assessments were not comprehensive, were not always undertaken by senior staff and the written documentation in respect of this was poor. Important information was omitted at times. As a consequence of this inappropriate trial visits were arranged and the Home were not able to meet the needs of all residents that came to live there. A resident who had recently come to live at the Home was extremely distressed and agitated on the day of the field work visit, was constantly venturing outside on to the front driveway of the Home and required specialist care that Madeleine House could not provide. There was evidence that the Home had received written information about the resident’s individual care needs prior to admission and it was clear that the individual’s care needs could not be met at Madeleine House. However despite this the resident was admitted to the Home causing unnecessary distress to both the individual resident and other residents living at the Home. It was noted that the management team on duty during the fieldwork visit were acting in the best interests of the resident to resolve this unacceptable situation. Plans were in place to introduce a comprehensive pre admission assessment document and the system for undertaking the assessments was being reviewed. Madeleine House has a category of registration to accommodate a maximum of five residents with dementia care needs, however it was apparent that more than five people currently residing at the Home were exhibiting confusion, disorientation and aggressive behaviour. The Organisation had recently undertaken an analysis of this in order to plan for the future services to be provided at the Home. More than the agreed number of residents with dementia care needs must not be admitted to the Home until a formal application has been made to CSCI and this has been agreed in order to ensure that the needs of all residents living at the Home are being met. One resident said, “ They have got far more than five people here who are confused and some have disruptive behaviour”. Intermediate care is not provided at Madeleine House. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to this service. Residents are involved in the care planning process and this ensures that their preferred daily routines are maintained. There were comprehensive risk assessments for residents that included strategies for minimising any risks in order to safeguard residents. Residents’ ongoing health and personal care needs were well met however inadequate written documentation in respect of this may potentially put residents at risk. The system for the management of medication is poor and does not safeguard residents. Residents are supported in a respectful manner by the staff working at the Home and this ensures that the residents’ dignity and self esteem are maintained. EVIDENCE: Comprehensive assessments of residents’ individual care needs are undertaken on admission to Madeleine House and a number of residents and their families had contributed to these in order to ensure that their preferred routines are maintained. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 13 Assessments included detail of the physical and medical health of residents, any religious beliefs and preferences in respect of their daily lives and routines. The assessments identified the limitations of individual residents in not being able to meet their daily living needs independently however, care plans had not been derived from this information in order to identify to staff the specific support that they must give in order to meet individual residents’ care needs. A number of care plans about the mental health needs of residents were recorded in good detail and identified any strategies required by staff in order to promote the mental well being of individual residents. Personal risk assessments had been undertaken including the risk of residents developing sore skin, malnutrition, moving and handling and going outside of the home alone and these included good detail of the actions required by staff in order to minimise any risks involved. The daily reports were found to be repetitive and non descriptive and did not reflect how the residents spend their time whilst living at Madeleine House. Care reviews involving residents, their families, health care professionals and the key worker are undertaken every six months and this ensures that the resident’s individual care needs are being met whilst living at Madeleine House and provides residents and their families with an opportunity to discuss the care that they are receiving and put forward any suggestions for improvement, if any. One resident said, “My care plan speaks volumes and we have a review of it every six months” A key worker system is in place and this is currently under review to include “associate key workers” ensuring that residents have the opportunity to speak with their significant staff members at any time that they choose. One resident said “If I need the support my key worker gives it to me” Residents have access to visiting health and social care professionals including community nurses, dentists, chiropodists, opticians and dieticians. Residents have the option of retaining their own general Practitioner on admission to the Home (if the GP is in agreement). One resident said “The staff arrange appointments with my doctor for me”. The staff refer to these visiting professionals for support and advice as required ensuring that the residents health and social care needs are being met. Residents appeared to be well groomed and supported by staff to choose clothing and jewellery appropriate for the time of year, their tastes and gender. Following assessment, residents have the option of self administering their own medication in order to maintain their independence whilst ensuring their Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 14 safety. Individual suitable lockable facilities are provided for the safe storage of this medication. The management of medication at the Home was poor and this puts residents at risk. There were a number of areas of concern as follows: • Medication had been administered at the wrong time and had not been signed for as confirmation of administration. • A number of prescription labels did not state the instructions for the administration of the medication. • The temperature of the medication fridge had not been recorded each day. • Prescription creams had not been signed for as confirmation of administration. • The actual amount of medication administered in respect of variable doses was not recorded and this prevents staff from monitoring the effectiveness of medication prescribed. • Medication audits had not been undertaken. • Three bottles of the same controlled medication for one resident had been opened by staff and it was unclear how the stock balance of this medication was being measured. The Inspector was informed that it had been agreed that a member of the management team from another care home within the Organisation would audit the system in use for the management of medication at Madeleine House and implement new policies and procedures to improve the standard of care in this area in order to safeguard residents. Residents stated that they are supported by staff in a respectful manner and staff do not enter residents’ flats without being invited as appropriate. Residents are issued with keys to their flats in order to maintain their independence and privacy. One resident said, “ My flat is very homely. The staff respect my privacy and don’t go into my flat unless invited” A pay phone was available for residents to use in a private and quiet area of the Home. Care plans identified the preferred names of residents and staff were observed greeting residents using these names in order to respect the identity of individual residents. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 15 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, 14, 15 Quality in this outcome area is good. This judgement was made using available evidence including a visit to this service. The activities on offer and opportunities for residents to pursue their leisure and religious worship interests meet the needs and expectations of residents living at the Home. Residents are supported by the staff to maintain contacts with their friends and family. Residents are given choice and freedom to make decisions regarding their daily lives and this promotes their independence and individuality. Residents receive a choice of wholesome meals which meet any special dietary needs for reasons of health, religion, culture or personal tastes. EVIDENCE: An activities co coordinator is employed at the Home for 20 hours each week and it is pleasing that she has completed a course in “creative activities for older people”. Positive comments were made about the choice of activities on offer including quizzes, crafts/art, bingo, entertainers, clothing sales and games. Trips out side of the Home are arranged including a recent trip to Aston Hall and a local garden centre. A summer fete had been held recently. The Home has a hairdressing salon and this is open twice a week. Suggestions for forthcoming events and reviews of the success of previous events are discussed during residents meetings in order to ensure that Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 16 residents have an input into the activities on offer at the Home taking into account the different interests of the residents living there. One resident said, “ We all get on well here, the company is the most important thing”. Individual activity and social care plans had been written and these identified any particular interests or support required from staff in this area Residents are free to pursue their chosen religions and there are opportunities for worship both within and outside of the Home. Holy Communion is available at the Home every fortnight, a Baptist church service is available at the Home each month and residents of other faiths are supported to visit their places of worship or arrangements are made for them to be visited at the Home. There is an open visiting policy at the Home and one resident said, “ My family are made to feel welcome here when they come”. Residents are able to exercise their control over their daily lives and can choose where they are served their meals within reason. One resident said “ I have my lunch in the dining room and my tea in my flat”. Following a risk assessment, residents are able to go outside of the Home on their own or with their families and friends as they choose and this ensures that their independence is respected whilst maintaining their safety. One resident said, “ I let the staff know when I am going out” Another resident said, “ I enjoy walking around the garden and I venture to the shops. I go in a taxi to my family’s house”. Following recent staff training, revised care practices have been introduced at mealtimes regarding the laying up of the dining tables and the serving of meals. Menus were available on the dining tables and these reflected the menu choices of the day and identified any alternatives to this. Residents are offered a choice of two main meal options at lunchtime and the care staff present the two prepared meals to the residents in order for them to decide which meal they would like to eat. There was a choice of at least three sweet options at lunchtime and fresh fruit was available. One resident said, “ I have enjoyed having a salad in this hot weather, especially prawn”. Residents are involved in the devising of new menus and any suggestions put forward by residents about new meal options are acted upon. It was pleasing that a “Food Comments Book” was available in the dining room which included the following comments:“ The food was really appetising” and “The buffet was very good”. Special diets can be arranged for reasons of health, religion or cultural preferences although there is no need for this at the current time with the exception of diabetic diets. Snack meals are available at suppertimes and this Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 17 ensures that residents are not hungry during the night and the well being of residents is maintained. Special themed meals are arranged in order to make meal times a social event for residents to enjoy. A barbeque had recently been enjoyed and a café royal event is planned for October. The menu on display on the wall outside of the dining room and copy given to the Inspector did not reflect the menus on the dining tables or the meal options on the day of the fieldwork visit. It did not identify the alternatives to the main meal options available and were found to be repetitive, for example, jacket potatoes were available twice in one day and only fish was identified as being available on a Friday. This was found not to be the case and other meal alternatives were available on these days. The sweet options were not identified and the sandwich fillings available were not identified. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement was made using available evidence including a visit to this service. The complaints procedure is comprehensive and is accessible to residents and visitors should they need to make a complaint. Any concerns or complaints received from residents or their visitors are dealt with in an appropriate and timely manner. There are robust systems in place to protect residents from abuse. EVIDENCE: Since the last fieldwork visit, no complaints, concerns or allegations had been made directly to CSCI. There was a comprehensive complaints procedure on display in the reception area of the Home and this was written in a large print format for ease of reading. Compliments, concerns and complaints booklets were readily available for residents and their visitors to complete should the need arise. The Acting Manager had commenced a complaints register on the day prior to the fieldwork visit and this identified two complaints made by relatives of residents living at the Home regarding care and health and safety issues. There was evidence that these were investigated by the Acting Manager in a timely manner to the satisfaction of the complainants and practices were revised in response to the complaints. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 19 One resident said “ I would go to the office if I had to complain, but I haven’t had to”. Staff had recently undertaken training in respect of the protection of vulnerable adults and the adult protection procedure included local Multi Agency Guidelines. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 20 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, 20, 21, 22, 24, 25, 26 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to this service. Residents are provided with a homely, clean and comfortable environment in which to live. Residents are encouraged to personalise their bedrooms in order for them to feel safe and secure in their surroundings and to reflect their individual tastes. Remedial action is required in respect of the security of the premises in order to safeguard vulnerable residents. The facilities and equipment available at the Home meet the needs of the residents living there. Poor practices in respect of the cleaning of soiled laundry may result in the spread of infection. EVIDENCE: The external garden area was well maintained, suitable for both fully mobile and wheelchair users and there was garden furniture provided for residents to use. The garden was open and lead onto the front driveway of the Home and road. Consideration must be given to making this area secure due to the number of vulnerable residents living at the Home. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 21 Since the last fieldwork visit a number of areas of the Home had been redecorated and a spacious and attractive conservatory had been built adjoining the dining room for the residents to enjoy. A slight step up in to this area is a trip hazard for residents. This was brought to the attention of the Acting Manager who stated that remedial action would be taken without delay. The communal lounge is divided by comfortable chairs in to two areas and whilst space in this area appeared to be limited due to the arrangement of the chairs, residents met during the fieldwork visit stated that they were happy with this. Plans were in place to improve the lounge area and a fireplace and new television had been purchased in order to enhance the quality of the internal environment for the residents living there. The carpet in the area of the lounge that was previously a designated area for smoking was damaged with cigarette burns and must be replaced. There were four assisted bathing facilities and these met the needs of the residents living at the Home. A competition was underway amongst staff to redecorate these areas of the Home with a prize for the most imaginative idea in order to provide relaxed and comfortable environments for residents to use when bathing. There were two hoists available for staff to support residents with physical impairments or following a fall in order to safeguard both residents and staff, however there was not a need for these to be used regularly at the current time. Handrails were available in the wide corridors and near to toilets and pressure relieving equipment was available for residents deemed to be at risk of developing sore skin due to reduced mobility. The building is suitable to accommodate wheelchair users and there is a passenger lift to all floors. Residents’ flats were spacious, decorated to a good standard and contained furniture, furnishing and personal items that reflected individual residents’ tastes and interests in order to ensure that they felt comfortable in their surroundings. There was carpet in some flats and others contained flooring of a hard surface type. There was a call bell facility in each flat in order for residents to summon assistance from staff if required. The temperature within the Home was comfortable on the day of the visit and the Home was found to be clean and fresh. Hygienic hand washing facilities were suitably located. One resident said, “ The cleaners clean our flats to an acceptable level”. Despite appropriate equipment being available, the Inspector was informed that soiled items of residents’ personal clothing are manually soaked in a sink in the laundry before being washed in one of the machines. This unhygienic practice may cause the spread of infection. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to this service. The Home provides staff in adequate numbers to meet the needs of residents and staff undertake appropriate training to improve their knowledge of caring for older people. The Home does not use agency staff and this ensures continuity of care. There is a robust system for staff recruitment in place and this protects residents. EVIDENCE: The staffing rotas identified that the Home were working within approved minimum staffing levels, no staff were working an excessive amount of hours each week and a senior member of staff was on duty at all times. Agency staff are not used and the Home has developed it’s own “bank” of casual staff and this ensures continuity of care. One resident said, “ The staff are kind and attentive here”. Kitchen, cleaning and laundry staff provide ancillary support to the care team on duty and this ensures that residents are supported in all aspects of their daily lives. Senior Care staff provide on call support to each other and this is being reviewed to ensure that the management team have an input in to this to ensure that senior staff feel supported at all times in the event of an emergency or for advice. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 23 There had been a high turnover of staff since the last fieldwork visit and a number of new staff had commenced employment at the Home recently. Staff recruitment files included all information required by regulations and this safeguards residents. All staff working at the Home had criminal records clearance and were deemed by the Organisation to be safe to work with vulnerable people. New staff undertake comprehensive induction training to ensure that they have the appropriate knowledge to work in a competent manner and this safeguards residents. Staff had received training appropriate to their job roles including dementia care, continence care, dining with dignity, accredited safe handling of medicines and end of life care. 34 of care staff have achieved NVQ Level 2 in Care and a number of staff are currently working towards this, ensuring that staff have the appropriate knowledge and confidence to work in a competent manner. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 24 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 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to this service. The Home was in need of a permanent management team that could offer guidance and direction to the staff to ensure that the health, safety and welfare of residents are maintained. In the interim, the Acting Manager was managing the Home in the best interests of the residents. The systems for resident consultation are good and there is evidence that the residents’ views sought are acted upon. The Home is regularly monitored for quality. The system for the management of residents’ personal allowances is robust and this safeguards residents’ money. Maintenance checks of equipment used at the Home are undertaken and staff are trained in respect of health and safety issues to ensure that residents’ safety and welfare are protected. Vulnerable adults have free access to the laundry and their safety may be at risk if unsupervised in this area of the Home. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 25 EVIDENCE: An experienced Registered Manager from the Organisation had been seconded to Madeleine House until the new Manager commenced employment in September 2006. In addition, a new Deputy Manager had recently commenced employment at the Home and support was provided from External Managers and the Administrator, who had a good knowledge of her job role. There was evidence that residents are consulted about aspects of the running of the Home, for example there was a prize competition to name the corridors of the Home. Residents meetings are held regularly and there was evidence that any suggestions put forward by residents are acted upon. Minutes of these meetings are available for residents who are unable to attend, ensuring that they are kept up to date with any information of interest. The minutes are also available in a large print format for residents with poor eyesight. One resident said, “ I go to the meetings, they are useful. The Home does their best to listen to our suggestions”. Staff meetings are also held regularly ensuring that staff have the opportunity to put forward their suggestions for improving the services provided at the Home and in order to keep staff informed about any changes to policies or procedures or training opportunities. Quality monitoring visits are undertaken regularly by External Senior Managers. A formal quality assurance system is in place to ensure that the standard of service provided at the Home is monitored and any shortfalls are addressed. The outcome of the most recent audit undertaken by an independent Organisation identified that the Home met the required standards identified within the auditing process and a report of the findings of this was accessible to residents and their visitors. 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 was a rolling programme of mandatory staff training in place, including back care, health and safety, fire safety, food hygiene and first aid and this ensures that staff work in a competent and safe manner. A fire drill had been undertaken recently to ensure that staff have the appropriate knowledge to respond safely in the event of an emergency and safeguard residents. Maintenance checks on equipment used at the Home are undertaken regularly in order to safeguard residents. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 26 The front door of the Home did not have an appropriate lock fitted in order to safeguard residents with dementia care needs and this was addressed by the Acting Manager without delay. The laundry door had been wedged open as the magnetic closure fitted on to it was broken. This would prevent the door from closing, placing all people within the building at risk in the event of a fire. The laundry door did not have a lock and a cleaner and disinfectant had been left on the sink within this area of the Home which would be harmful to the health of vulnerable residents if accidentally swallowed or spilt. Records of all accidents involving residents are kept, CSCI are informed of these and appropriate medical advice is sought without delay. However written evidence of any actions taken or outcomes following accidents was not always available and this did not reflect the actual care that the residents had received. Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 27 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 2 X 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 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 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4 5 14(1) Requirement The statement of purpose and service user guide must be updated to reflect the current service provided at the Home. A comprehensive assessment of prospective residents’ individual care needs must be undertaken by a suitably trained and competent senior staff member using a pre admission assessment document that is fit for purpose. Residents must not come to live at the Home unless their pre admission assessment has identified that their individual care needs could be met at the Home. The Acting Manager received this in the form of an immediate requirement. Residents must not be admitted 01/10/06 outside of the Home’s current categories of registration and the organisation must consider to submit to CSCI an application for variation to accommodate more than five residents with DS0000016912.V308423.R01.S.doc Version 5.2 Page 29 Timescale for action 10/10/06 2. OP3 24/08/06 3. OP4 14(2) Madeleine House dementia care needs in order to formalise this. An action plan must be submitted to CSCI regarding this. Care plans must 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. (Previous timescales of November 2003 and 30/01/06 not met) Daily reports must be recorded in more detail and include information about the activities that the resident has engaged in during that day, any visits from health and social care professionals and evidence of the support provided to the resident by the staff team. The management of medication 24/08/06 requires further development to include: • Medication (including prescription creams) must be administered as prescribed at the correct time and must be signed for on the medication administration chart (MAR) as confirmation of administration. 4. OP7 15 01/11/06 5. OP9 13(2) The Acting Manager received this in the form of an immediate requirement. • The actual amount of medication administered in respect of variable doses must be recorded on the MAR chart Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 30 (Previous timescales of November 2003, 25/5/05 and 30/11/05 not met) • Arrangements must be made with the dispensing Pharmacist for prescription labels to identify full dosage and administration instructions of medication prescribed. The temperature of the fridge storing prescription items must be recorded daily Medication audits must be undertaken Procedures for the monitoring of stock balances of liquid controlled medication must be reviewed. 15/09/06 • • • 6. OP19 13(4) 7. OP20 8. 9. OP20 OP26 10. 11. OP28 OP36 Consideration must be given to making the garden area secure due to the number of vulnerable residents living at the Home. 13(4) Remedial action must be taken to rectify the slight step up in to the conservatory, as this is a trip hazard. 23(2)(d) The damaged carpet in the lounge area must be replaced. 13(3) Staff must not manually sluice soiled items of residents’ personal clothing and must use the appropriate equipment provided. 18(1)(a)(c 50 of care staff must be )(i) awarded NVQ Level 2 in Care 18(2) All care staff must receive formal supervision at least six times each year. This requirement was not assessed on this occasion. A suitable lock must be fitted to the front door in order to safeguard vulnerable residents DS0000016912.V308423.R01.S.doc 07/09/06 01/11/06 07/09/06 31/12/06 31/10/06 12. OP38 13(4) 25/08/06 Madeleine House Version 5.2 Page 31 13. OP38 23(4) The Acting Manager received this in the form of an immediate requirement. Fire doors must not be wedged open and magnetic closures fitted on to fire doors must be in good working order The Acting Manager received this in the form of an immediate requirement. Substances hazardous to health must be stored securely at all times. The Acting Manager received this in the form of an immediate requirement. A suitable lock must be fitted to the laundry door The Acting Manager received this in the form of an immediate requirement. 25/08/06 14. OP38 13(4) 24/08/06 15. OP38 13(4) 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The menu on display should reflect the menu options of the day and identify any alternatives to the main meal options, types of sandwich fillings and the sweet options available. A record of any action taken and outcomes following an accident involving a resident should be kept. 2. OP38 Madeleine House DS0000016912.V308423.R01.S.doc Version 5.2 Page 32 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 © 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.V308423.R01.S.doc Version 5.2 Page 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!