Inspection on 22/11/05 for Magnolia House

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Magnolia House 03/09/07

Magnolia House 22/11/06

Magnolia House 11/07/05

Magnolia House 30/01/05

Magnolia House 27/07/04

Magnolia House 08/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Magnolia House 11 Station Road Biggleswade Bedfordshire SG18 8AL Lead Inspector Mr. Pursotamraj Hirekar Unannounced Inspection 22/11/05 15:05 Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 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 Magnolia House DS0000014934.V267386.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 Adults 18-65. 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. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Magnolia House Address 11 Station Road Biggleswade Bedfordshire SG18 8AL 01767 315562 01767 317586 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) Community Care Solutions Limited Sheira Plentie Care Home 5 Category(ies) of Learning disability (7) registration, with number of places Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 7 people, 5 in the main house and 2 in the bungalow. The home can accommodate a maximum of 7 people in the category learning disability (LD) The home may accommodate up to 1 person who has a physical disability or sensory impairment if their primary assessed need is a learning disability. This person must be accommodated in the ground floor bedroom of the main house. The bungalow must only be used for those service users that are working towards more independent living as part of their agreed plan of care. 11 July 2005 4. Date of last inspection Brief Description of the Service: Magnolia House was first registered in 1999 to provide residential care to 7 adults with learning disabilities. The home is a family house which has been extended to provide five single bedrooms in the main house and 2 in the bungalow, one of which is on the ground floor, a large kitchen/diner, lounge and conservatory. There are bathing and toilet facilities on both floors and a small office/sleep-in room on the first floor. The home is within walking distance of Biggleswade town centre, with its shops, library, pubs and places of worship. The current service user group are all between 25 and 50 years and all have learning disabilities. They also need varying degrees of support with behaviour that may be challenging. The home aims to enable people to live as independently as possible whilst receiving care and support to enable them to access the local community. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection that took place on 22 November 2005 over three hours by Pursotamraj Hirekar and Colin Bowker. The method of inspection included review of service users’ care plans, risk assessments review of arrangements for service users care and their private accommodation, communal lounge, kitchen, toilet. Conversations took place with one service user, manager and the area manager. What the service does well: 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. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Owing to assessments not undertaken by competent staff, the needs and aspirations of the service users are at risk. EVIDENCE: The service users whose situation was case tracked, indicated that the needs and aspirations were assessed. The service user had a written contract signed. However, it is not clear from the assessments that a competent person who is qualified and experienced to assess challenging behaviour, assessed the needs of the service user. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The home does not have a clear and consistent approach to care planning that will meet the changing needs of the service users. EVIDENCE: The service users’ care plans dated December 2004 to June 2005 and June 2005 to December 2005 had the same information about the service user including same font size. However, the service user and the manager signed the care plans. The home manager has confirmed that the information contained in both the care plans is same. Changes in care plans have not been recorded. The risk assessments were not reviewed and care plan is not updated to meet the changing needs of the service user. The area manager had confirmed that the home had recently developed a care plan review tool, which they will be using from December 2005. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 & 17 Service users have enough opportunities for personal development and have no complaints about the food. EVIDENCE: The home had made arrangements for the service users to attend college and a farm during the daytime. The service user spoken to confirmed, that they enjoyed college and farm work. The home had not given any evidence with regard to the service users leisure and culturally appropriate activities including any weekend activity plan. Service users were content with their meal timings and quality of food. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 In the absence of a policy and procedure for the administration of medication by the staff potentially places service users at risk. EVIDENCE: Service users’ were being supported to receive regular health checks. The members of staff control and administer the medication. However there is no evidence given on inspection to support that the home had a policy and procedure for staff members to administer medication. Further, there was no evidence given to support that staff members were trained prior to their administering medication. The home must provide learning disability specialist services on a regular basis to identify risks and provide necessary services to the service users’ with challenging behaviour. It is also important to record changes and developments that take place with the service users. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Arrangements for protecting service users are not satisfactory thereby placing them at risk of possible harm. EVIDENCE: The home complaints files inspected had no information with regard to the home’s policy and procedure to deal with complaints and protection of vulnerable adults. The home manager did not have sufficient knowledge and skills in dealing with protection of vulnerable adults issues. The home has no record of evidence of any complaints having been made so far. The manger confirmed that there are no complaints received since September 2005. However, service users needed to be provided with information and explained time and again about the procedures and how to lodge complain. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home was comfortable and safe for those living there and visiting there and for visitors EVIDENCE: The service users whose situations were case tracked had comfortable bedrooms that suited their needs and lifestyles to promote their independence. The toilet seat on the ground floor was broken and needed replacement. The tour of the home’s manager’s room, conservatory, lounge, and kitchen were found clean and hygienic. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 There is no evidence at home to ensure staff vetting and recruitment practices are appropriate and does not harm the service users’ EVIDENCE: The home was not able to provide any evidence on inspection with regard to the home’s recruitment policy and practices, staff vetting records, including qualification, experience, CRB, references, protection of vulnerable adults register check as required by the legislation. Also, there was no supporting evidence about staff training and competence to perform specific roles and responsibilities to meet the changing needs of service users’ to improve their quality of life. The area manager and the home manager have confirmed to provide the above details to CSCI in next 14 days from the date of inspection. The area manager, home manager have joined Advance in September 2005 along with two support workers in the home. The two new support staff have built satisfactory working relations with the service users. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, The manager does not have a good understanding of the care legislation and areas in which the home needs to improve. EVIDENCE: There is no registered manager for the home. The current manager had joined Community Care Solutions in September 2005. At the time of this inspection, the manager had confirmed with the inspector that she is making effort to understand, locate relevant documents related to service users, staff and the home, to systematically organise them. The manager was not able to give sufficient information about the day-to-day management of the home, and had not provided enough evidence to consider service users’ views to the effective management and development of the home. The manager is planning to make an application to CSCI for registered manager. Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 1 X 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 1 X 1 X X X X Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 16 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 32 Regulation YA 18 (1) Requirement Timescale for action 01/02/06 2 3 4 34 37 39 5 6 The home must ensure that staff employed are suitably qualified, competent, experienced and receive training. YA17(2) The home must ensure staff’s Sch4(6) vetting records are maintained at the home. YA9(1) (2) The home must ensure that the Sch2 manager is fit to manage the home. YA24(1) The home must ensure a robust YA15(1) care planning and review system to meet the service user’s health and welfare needs. (Previous requirement 31/08/2005) YA14(1)(2) The home must ensure service user’s needs are assessed by a suitably competent person and are regularly reviewed. 15/12/05 01/02/06 01/02/06 01/02/06 Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 17 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 5 6 Refer to Standard 2(1) 14 20(1) 22(3) 23 29(2)(v) Good Practice Recommendations Undertake full assessment of service users by people competent to do so Service users should be provided with enough simulation and are engaged in appropriate leisure activities The home should ensure to comply with policy and procedure for receipt, recording, storage, handling, administration and disposal of medicines The home should ensure to give a copy of home’s complaints procedure and / or explained to each service user in an appropriate language/ format The home should ensure that a robust procedure for safety and protection of service users is in place. The home should ensure appropriate bathroom fittings Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Magnolia House DS0000014934.V267386.R01.S.doc Version 5.0 Page 19 - 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. 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