Inspection on 27/06/07 for Majestic Care Home

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Majestic Care Home 15/10/09

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Majestic Care Home 192 Queens Promenade Bispham Blackpool Lancashire FY2 9JS Lead Inspector Mrs Ruth Edgington Unannounced Inspection 09:15 27 &29thJune 2007 th 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 Majestic Care Home DS0000069193.V338413.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. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Majestic Care Home Address 192 Queens Promenade Bispham Blackpool Lancashire FY2 9JS 01253 351612 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) Sunshine Care Homes Ltd Lynne Susan Barlow Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 19 Date of last inspection New Service Brief Description of the Service: The Majestic is registered to provide personal care for a maximum of 19 residents of either sex whose primary care needs are those of old age. The home is an adapted property, which is situated on the promenade at Bispham and is close to local shops and amenities. The accommodation comprises of 19 single bedrooms, of which 14 have en-suite facilities. There is a large lounge and dining area and also a small sun lounge in which residents and their relatives can sit if they wish more privacy. There are sufficient bathing and toilet facilities to meet the needs of the residents accommodated. A stair lift enables residents to gain access between the ground and first floor. Various aids are available to assist residents in their daily lives. The home has a Statement of Purpose and Service User Guide providing information about the care provided, the qualifications and experience of the owners and staff and the service that residents can expect if they choose to live at the home. Prospective residents and their relatives are provided with sufficient information to help them to make an informed choice about whether to move into the home. The range of fees at the home are £332.0 to £360.0 covering all aspects of care, food and accommodation. Additional charges are made for chiropody and hairdressing. The manager provided this information on 27th June 2007. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection undertaken since the new owners purchased the home in March 2007. An unannounced site visit was undertaken as part of the Key Inspection and commenced at 9.15am on 27th June 2007. A further visit was made on the 29th June and in total 6 hours was spent in the home. Prior to the visit the manager completed an Annual Quality Assurance Assessment document (AQAA), which provided information about the home and how the service provided was meeting the National Minimum Standards. Comments cards were sent out to six of the residents, their relatives and any persons who had significant dealings with these residents. In total only one health care professional, two relatives and all questionnaires sent to the residents were completed and provided views of about the service. During the visit three residents, three members of staff, the manager and the one of the homeowners, who was registered as the Responsible Individual, were spoken to. A random selection of residents, staff and administrative records were looked at and a tour of the home took place From observations made, comments received and written documentation examined, the information has been put together to produce this report. What the service does well: What has improved since the last inspection? Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 6 This is the first Key Inspection undertaken since the new owners purchased the home in April 2007. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 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 Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures are clear to ensure that the care needs of residents are met. EVIDENCE: The admission process includes a full assessment of the needs of any prospective resident, which is undertaken by the manager or a senior member of staff who is competent to carry this out. The prospective residents and their representatives are involved in the assessment to ensure that the home can meet their assessed needs. The records of three residents were looked at in detail and were found to contain full assessment information that had been obtained prior to admission therefore ensuring that the home could meet their assessed needs. The information included the physical, emotional, dietary, religious and cultural needs. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 9 Evidence was seen that they had received confirmation in writing before their admission that the home could meet their assessed needs and informing them that a care plan would be developed to ensure that their needs continued to be met. From observations made and comments received during the visit, evidence was found that the staff were well aware of the needs of the individual residents. This home does not provide intermediate care. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously, resident’s welfare is closely monitored and health needs were met. EVIDENCE: Examination of the three residents’ records that had been selected to be looked at in detail were found to contain sufficient information to ensure that their health, personal and social care needs were met. The individual care plans had been developed with the involvement of the resident and where required their relatives. Risk assessments were included which identified the level of risk and the intervention required by the staff. Significant events were recorded and daily entries made of the care given. Evidence was seen of involvement of health Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 11 care professionals, this included the provision of pressure relieving equipment if required and advise from the continence advisor. Comments received from one health care professional confirmed that the staff sought advice when required and acted upon it. They said that they found that the health care needs were being met and that residents’ privacy and dignity was promoted. Concerns were raised in the questionnaires received from one resident and their relative about difficulties in getting a chiropodist and the reluctance of the doctor to visit. The manager confirmed that a chiropodist visited every 6-8 weeks and that the doctors were always asked to visit when required. The manager felt that the situation had now been resolved and when spoken to the resident in question did not indicate that they were unhappy with the care that they were receiving. Evidence was available of the monthly reviews carried out to ensure that the care plans continued to meet the individual needs. Observations were made during the visit of the caring attitude of the staff and how they assisted the residents with their personal care, ensuring that their right to privacy and respect was upheld. One resident commented that the staff were very good and they were glad that they had them. All staff are made aware of the medication policies and procedures in the home and training is given to those who administer the medication to ensure that the residents are protected and that their needs are met. Examination of the medication records confirmed that these were correct, up to date and kept secure in a locked cabinet. It was noted that one resident who takes responsibility for their own medication was not keeping it in the locked facility provided. The manager confirmed that she would discuss this with the resident in relation to the protection of other residents. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social activities and meals are both well managed, creative and provide variation and interest for people living in the home. EVIDENCE: Information recorded on each resident’s file includes reference to their preferences, interest, social, religious and cultural needs, which is all used to ensure individual needs are identified and met. Evidence was seen that residents are helped to exercise choice and control over their lives within their capabilities. One resident spoken to said that they were happy to sit in their bedroom as they enjoyed reading. One member of staff spoken to confirmed that they had taken on the responsibility of arranging activities for the residents, which included games, quizzes, watching videos and was in the process of introducing arts and crafts for those who wished to take part. They said that they had developed an entertainment book, which is available to all and outlined the activities taking place. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 13 During the visit the vicar from the local church attended to give communion to some of the residents, which those who wished to attended. One resident enjoys watching films and listening to music in their own bedroom and observations of their bedroom showed that they had a very large collection of Videos and CDs that they had acquired. There is a garden at the front which residents are encouraged to sit out in the better weather. One relative had commented about residents being encouraged to sit out in the good weather and becoming involved in activities, which from the information received during the visit was now being done. The choice to participate is that of the residents and is also dependent on their individual abilities. One resident spoken to said that they were very happy with the home and was observed feeding the birds, a task that they did very day. Information received prior to the visit indicated that the manager and staff intend to further promote entertainment options to ensure that residents to enjoy a full and stimulating lifestyle. Visitors are made welcome and this was confirmed through observations made during the visit of a number of visitors who came into the home and spent time with individual residents. Information was recorded on each resident’s file indicating their dietary needs, likes and dislikes. Examination of the menus showed that the meals were nutritious and well balanced. A record was kept of all meals served. The staff spoken to said that they had sufficient information regarding individual dietary needs to ensure that these were met. Comments received from residents confirmed that they were satisfied with the meals provided. One resident said,”I enjoy the food and get plenty to eat”. From observations made during the visit, evidence was gained that the residents were encouraged to be independent in their thoughts and actions. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to, taken seriously and they will be protected at all times. EVIDENCE: There is an appropriate complaints procedure in place, which is clearly written and easy to understand. This is included in the information provided to the residents and a copy is displayed in the hallway of the home. Comments received from residents and relatives confirmed that they knew who to complain to if required. The Commission for Social Care had not received any complaints since the new owners took over the home. Through discussions evidence was gained that the staff have a good understanding of the procedures to be followed in the event of any allegation or suspicion of abuse or neglect. The manager confirmed that they intend to access further training that is being provided by the local authority in relation to Safeguarding Adults to ensure Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 15 that staff continue to update their knowledge for the protection of the residents. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The planned maintenance and renewal programme for the redecoration and refurbishment of the home continues to ensure that residents live in a comfortable, homely, clean and safe environment. EVIDENCE: The new owners have made numerous improvements in a very short period of time. The manager has commenced an improvements file in order to identify the work required and monitor when this has been completed. The improvements included, the replacement of a canopy to the front of the building, repair and painting of upstairs windows, painting of the external aspects of the home and the appointment of a gardener, all of which have improved the overall look of the home and ensure that the residents have pleasant surroundings in which they can sit out in the good weather. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 17 A programme for replacement of bedroom carpets and furniture was in place and evidence was seen of this. The owners have replaced the washers and dryers, which has improved the laundry process ensuring that residents clothing is returned to them quickly. Limited internal storage space was discussed with the manager and owner who confirmed the intention to build an outside storage space to resolve this situation. On the first visit to the home some concerns were raised over storage and the general untidiness that this caused. By the time that the inspection was concluded this situation had been resolved. Comments had been received prior to the visit from a relative who was concerned at the size of the bedrooms and the state that these were kept in. The person was advised that the rooms met the minimum size required and that the state that residents wanted to keep their rooms was their choice. The manager confirmed that the staff each had responsibility for ensuring that individual rooms were risk assessed and kept as clean and tidy as the residents wished. Another relative raised the question of a ramp to the front of the building to enable easier access to the garden for residents. The homeowner present confirmed that this matter would be looked into. The two steps that would have to be negotiated were not deep and the staff said that this had never been raised before as a problem. A ramp is sited at the rear of the building, which has been used in the past. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and training provided for staff ensure that the residents are protected and cared for by staff who are competent and qualified to undertake their role. EVIDENCE: There have been no new staff employed since the new owners took over. The file of a member of staff who was on duty was looked at in detail and was found to contain the documentation that confirmed that the correct recruitment procedures had taken place to ensure the residents were protected. The manager stated that she has introduced the key worker scheme and produced a handbook that includes the policies and procedures for staff to refer to, the structure of the home and the responsibilities of the key worker. Included were issues relating to equality and diversity. The manager confirmed that she had made contact with the Lancaster and Morecambe College to access relevant training course. Evidence was seen that over 50 of the care staff had achieved level 2 NVQ (National Vocational Training). Two care staff were due to commence level 2 and three were to commence level 3. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 19 One relative had commented that at times it was difficult to find a member of staff, however on the day of the visit there were sufficient staff on duty to meet the needs of the residents. It was suggested to the homeowner that consideration was given to increasing the domestic hours and he agreed that this would be considered in future developments of the service. Staff spoken to said that they felt supported and included in all aspects of the residents care. Comments received indicated that the staff were always cheerful and helpful. One resident stated the they will always try and sort out any problems that individuals had. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &39 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents. EVIDENCE: The manager had worked at the home for the previous owners in the position of senior carer and was appointed to the post of registered manager at the time of the new homeowners becoming registered with the Commission for Social Care Inspection. This has provided some stability for the residents and staff and she is supported by one of the owners who visits on a weekly basis. Following the visit the homeowner completes a report which is available in the home. For some residents who have lived at the home for a long time this was the third time that someone new has taken over and understandably they were Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 21 unsettled by this. The homeowner, manager and staff confirmed that they were working hard to reassure them and improve their quality of life. Through discussion the owner confirmed that he would continue to ensure that he spoke to every resident and as many relatives as possible to reassure them. The manager is an experienced, qualified and competent person however it was suggested that consideration should be given to the appointment of a deputy to assist the manager to achieve the improvements that were being identified to improve the service provided. The homeowner confirmed that this had been discussed with the manager and was being considered. The manager had completed the AQAA (Annual Quality Assurance Assessment) in a very detailed and professional manner, which clearly showed what they did well and how they felt that they could improve the service for the benefit of the residents. There was a clear understanding of the principles of equality and diversity and that residents should receive equal treatment and access the same resources without favouritism or discrimination. Quality assurance systems were in place to gather the views of residents and visitors. Information was provided that confirmed that all safety equipment was regularly service. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. The manager has produced a performance and develpoment plan setting out the objectives for the year. This document clearly indicates how these objectives are to be met and the timescale that has been agreed. The manager confirmed that this was to be completed annually in order that the needs of the residents continue to be met. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 22 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 1 Refer to Standard OP22 OP22 Good Practice Recommendations The provision of additional storage for aids and equipment should be considered to prevent these from becoming a hazard for the residents. The provision of a ramp at the front of the home should be considered to enable easy access for the residents between the conservatory and garden area. Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Majestic Care Home DS0000069193.V338413.R01.S.doc Version 5.2 Page 25 - 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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