Inspecting for better lives Random inspection report
Care homes for adults (18-65 years)
Name: Address: Magnolia House 185 Rockingham Road Kettering Northamptonshire NN16 9JA The quality rating for this care home is: The rating was made on: three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Catherine Perrins Date: 2 4 1 1 2 0 0 8 Information about the care home
Name of care home: Address: Magnolia House 185 Rockingham Road Kettering Northamptonshire NN16 9JA 01536518689 01536513989 magnolia@consensussupport.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Caring Homes Healthcare Group Limited care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability 19 Over 65 0 Conditions of registration: The Home is registered to provide personal care to service users as follows: Learning Disability (LD) - Magnolia House (10), Violet House (4), Lily House (5). Only one service user over the age of twenty five (25) years may be admitted to Magnolia House. Only service users between the ages of eighteen (18) and twenty five (25) may be admitted to Violet House. Only service users between the ages of eighteen (18) and twenty five (25) may be admitted to Lily House. Date of last inspection Brief description of the care home The last Key inspection for this service was 24th November, 2006. Magnolia House provides care and support to younger adults with learning disabilities/autistic spectrum disorders. An established home, Magnolia House was taken over by the current Care Homes for Adults (18-65 years) Page 2 of 10 provider June 2006. The premises consist of three units: Magnolia House, Lily House, and Violet House, which are all on the same site. Magnolia House and Lily House are refurbished Victorian properties, and Violet House is a purpose built bungalow. The home has 19 beds in total: 10 in Magnolia House (aged 25-65), four in Violet House (aged 18-25), and five in Lily House (aged 18-25). Violet House and Lily House mainly accommodate residents with autistic spectrum disorders, and Magnolia House caters for residents with learning disabilities. One Registered Manager is responsible for the three units, each of which has its own Team Leader and dedicated staff team. The home is situated on a main road into Kettering, and has good transport links and a car park. There is a secluded garden with seating areas and a barbecue at the rear of the property. Fees at the time of last key inspection ranged from 350 to 2,000 pounds per week. Care Homes for Adults (18-65 years) Page 3 of 10 What we found:
This was an unannounced random inspection arranged followed concerns about an incident where someone who lives at the home had been scalded while being supported to have a bath.The inspection focused on these concerns. Two inspectors carried out the inspection. As we felt that there had been a possible breach in the Care Home regulations relating to the health and welfare of the people who live at the home we served a Code B notice at the start of the inspection. This notice is issued in accordance with the Police and Criminal Evidence Act 1984 and explains our powers and rights. Records were copied and seized during the inspection and this evidence will be reviewed and considered in relation to possible enforcement action. The registered manager was not available at the time of inspection. The deputy manager was present during the inspection and the Responsible Individual was also present for part of the inspection. The deputy manager explained that the registered provider had arranged for a temporary manager to manage the home whist the Registered Manager is suspended pending investigation into this incident and other concerns. The Responsible Individual stated that an external consultant has been appointed to look at how the home is being managed. The downstairs bathroom in Magnolia House was refurbished in January 2008 and a new bath was installed. This bath has a built in device that limits the temperature of the hot water to 38 degrees Centigrade. Prior to the incident where someone was scalded this was the only hot water limiter fitted at any of the three the properties. The Responsible Individual confirmed that since the incident hot water limiters have been fitted to the boilers in each of the properties. Water temperature checks carried out during the inspection showed that the hot water was at an appropriate temperature in all but one of the bathrooms in the properties. The hot water temperature in this one bath was sixty three degrees centigrade which is 20 degrees hotter than the required temperature. The Responsible Individual stated that a new boiler had been fitted since the hot water restrictors were fitted to the boilers and that the new boiler supplied this bath. Having the water temperature that is this hot puts people at risk of being scalded. An immediate requirement was made at 16:10 to ensure that the affected bathroom was not used until the hot water temperatures are dispensed at safe temperatures. The Responsible Individual contacted the providers property services department to request an engineer visit the property later that day to look at the water temperature. She also confirmed that the bathroom would not be used until the temperature could be limited to the required level. The home has a prevention of burns and scalding policy which states that the provider Care Homes for Adults (18-65 years) Page 4 of 10 will fit appropriate and approved water temperate regulators Without question .....to all areas where there is a possibility of scalding. The Responsible Individual stated that the provider was planning to fit hot water limiters to all baths and sinks used by people who live at the home and that this would be done within one year. Further information received subsequently to this inspection shows an intention to expediate the fitting of thermostatic monitoring devices within the next 4 - 6 weeks. Records showed that the temperature of the hot water in the bathrooms had been checked three days prior to the incident however further investigation by the Responsible Individual confirmed that this check had actually been done on the pipework leading to the water outlet only, and not the water itself. The staff had been checking the temperature of peoples bath water using a thermometer, however a few days prior to the incident the thermometer had broken and was not replaced. Following the incident new thermometers have been purchased and were available in all of the bathrooms. Records show that there is limited understanding amongst staff about the correct temperature for bathing water temperatures range from 32 degrees to 40.7 degrees Centigrade. One of the records for Violet house stated that Bath temperatures should read no higher than 37 degrees Celsius and no lower than 25 degrees Celsius some where in between those two would be best. This entry is not signed to show which staff member had recorded this. There was a record of staff induction however this did not show evidence of instruction on how to bathe people safely. The deputy manager stated that individualised care plans provide detailed instruction to staff about how people are to be supported when bathing and that staff shadowed experienced staff to learn how to support individuals. There was no evidence to show that the staff member involved in the incident had received any training in health and safety prior to the incident. Following the incident she has been given an e learning health and safety course to complete on the computer but she has not yet completed this. Details of how to bathe people are recorded in their individual plans of care. The home does not have a bathing policy to cover everyone. The care plan for the person who was scalded had not been updated following the incident and still states .. the bath hot water will need to be gradually added to the bath to maintain the temperature at comfortable levels once she is in. The Responsible individual stated that she had given instruction to the home immediately following the incident that staff must not add hot water to the bath when anyone is in it. Staff spoken to said that they did not top up the hot water when people were in the bath. The deputy manager and the Responsible Individual stated that the previous care plan for this person had been destroyed by the registered manager so was not available to be seen at the inspection. Following the scalding incident the person involved was treated at the local Accident and Emergency department and received treatment from district nurses for a period of three weeks to ensure that her dressings were changed as needed. What the care home does well: Care Homes for Adults (18-65 years) Page 5 of 10 The provider is investigating the incident and the wider issues which may have led to the incident occurring. They have taken some immediate steps to reduce the risks to people living at the home such as the provision of new bath thermometers and fitting hot water regulators to the boilers in the three properties. The home has a Prevention of burns and scalding policy. The staff had been checking and recording the temperature of peoples bath water. Details of how to bathe people are recorded in their individual plans of care. Following the incident the person who was scalded received appropriate medical assistance. The provider reported the incident to the relevant bodies. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 6 of 10 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set.
No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 7 of 10 Requirements and recommendations from this inspection
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action 1 42 13 As of 16:10 on the 24th 28/11/2008 November 2008 the bathroom on the first floor of Magnolia House must not be used until the hot water temperatures are dispensed at safe temperatures i.e. near to 43 degrees Celsius. This is to ensure the heath and safety of the people who use the service. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 35 18 Staff must receive training in 31/05/2009 health and safety appropriate to the work they perform. To ensure that they are able to do their jobs in a way that safeguards their own health and safety and that of others. 2 41 17 Service users care plans must be kept up to date. To ensure that staff have to correct information to care for people in the agreed way. 24/02/2008 3 41 17 Records pertaining to the service users and the home as specified in schedules 3 and 4 of the Care Home 31/01/2009 Care Homes for Adults (18-65 years) Page 8 of 10 Regulations 2001 must be kept for at least three years from the last date of entry. To ensure that the relevant information about people who use the service and about the home is available when needed. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No. Refer to Standard Good Practice Recommendations 1 35 Staff induction should be consistent with the common induction standards and be documented to detail the areas covered. Care Homes for Adults (18-65 years) Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 10 of 10 - 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!
