Inspection on 02/11/05 for Malbary House

This inspection was carried out on 2nd November 2005.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Malbary House 08/06/06

Malbary House 25/07/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Malbary House Malbary House 45 Carlton Street Kettering Northants NN16 8ED Lead Inspector Mrs Sarah Smart Unannounced Inspection 2nd November 2005 09.30 Malbary House DS0000063226.V263713.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 Malbary House DS0000063226.V263713.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. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Malbary House Address Malbary House 45 Carlton Street Kettering Northants NN16 8ED 01536 312398 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) Mrs Jacqueline Mary Miller Mrs Jacqueline Mary Miller Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No Service Users with a Learning Disability may be admitted to the home where there are already 6 service users in the home. The total number of service users must not excees six (6). All service users must have a learning disability No further service users within the category of OP may be admitted to the home. 25th July 2005 Date of last inspection Brief Description of the Service: The home currently provides accommodation for four service users in the category of Young Adults with Learning Disability, and is registered for 6. The accommodation is laid out over two floors, offering four single first floor rooms, and a further ground floor double room, occupied by two service users who have chosen to share. The home also has a large lounge diner, a smoking lounge, a kitchen and utility room. There is a first floor bathroom, separate shower room, and a ground floor walk in bath. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 9.30 and midday. Preparation for the inspection included, review of the previous inspection report, and requirements, and took approximately 1 hour. The primary method of inspection used was ‘case tracking’. This involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The following areas were covered during the inspection: case tracking, medication, sample of policy review, staff rota, staff training, provision of activities, previous requirements made, and staff and service user interviews. One service user were case tracked. The manager, was interviewed, however there were no other staff in the home at the time of the inspection. One service users was spoken to in detail. What the service does well: What has improved since the last inspection? What they could do better: Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 6 Care plans could be more specific, should contain evidence of the service users involvement in the writing, and be dated, signed and reviewed. Further risk assessments need to be written. Medication storage must be improved. The abuse policy should contain additional information to ensure that the reader is adequately informed. 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. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 7 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 Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 8 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): 2,4 Prospective service users are adequately assessed, and introduced to the home and existing service users. EVIDENCE: The service user most recently admitted to the home was case tracked. A thorough needs assessment had been carried out. The owner/manager stated that a fifth service user has been assessed for admission to the home. She said that the service user had been to the home on several occasions, and stayed for tea with the existing service user. The service user in the home told the inspector that she had been able to get to know the other service users before moving into the home, as they had been introduced at various functions. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 9 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): 6,7,9,10 Service users individual needs and choices are given full consideration. One care plan should be more specific. EVIDENCE: One care plan viewed could have been more specific in the information it contained. Other care plans were satisfactory. None of the care plans contained evidence of the service users involvement in their writing, and were not dated or signed by the writer. The service user advised the inspector that she is afforded choices in relation to her daily activities, and a second service user was being supported in his decision not to attend the day centre. Some risks had been identified, although thorough risk assessments had not been carried out. An example of this is the risk of burns from hot water. A previous requirement had been made in relation to a risk assessment. The owner/manager had arranged for the boiler settings to be adjusted, and put warning signage in place, therefore reducing the risk, but had not produced a written risk assessment. The service user advised the inspector that she hope to be able to visit the nearby town centre alone soon, as part of her encouraged and increased independence. The owner/manager was advised that a written risk assessment Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 10 should be carried out in relation to this, prior to the service user going out alone. The service user stated that she had been advised of the homes protocol for visiting other service users in their own bedrooms. Documentation relating to the service users is stored appropriately. The owner/manager has recognised the need to ensure that conversations and telephone calls are held privately if necessary. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 11 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): 11,12,13,15,16 Service users are supported in their choice of lifestyle. EVIDENCE: The service user case tracked has her own computer equipment in her room, which she uses for education. Other service users attend local day centres where they partake in various activities. The owner/manager stated that the service users are encouraged to be active within the community. During the summer they attended a local bar-b-que. None of the service users currently choose to go to church. Documentation clearly stated the service users contact with their relatives and friends. Service users are encouraged and assisted to maintain links with their family and friends. The owner/manager demonstrated absolute respect for the service users rights. She is currently supporting one of the service users who has chosen not to attend the day centre on certain days, and is helping him to find appropriate alternative activities that are available. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 12 Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 13 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 The management of medication must be improved. EVIDENCE: A sample of medication was viewed. Records were maintained to an acceptable standard. A bottle was found with a handwritten label. The owner/manager stated that these belonged to one of the service users. The inspector advised that a correctly labelled container must be obtained. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 14 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): 23 The abuse policy should contain further information in order to adequately advise the reader. EVIDENCE: The abuse policy was viewed. The document did not contain all of the expected information. The owner/manager did not have a copy of the Northamptonshire Inter-agency abuse policy, and is strongly advised to obtain one, and this will give all of the required information. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 15 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): These standards were not assessed during this inspection. EVIDENCE: These standards were not assessed during this inspection. A requirement was made during the last inspection in relation to the ability to cancel a sounding call bell without attending the service user. Although the owner has not written a policy, as required, she stated that it had been discussed with the staff member. This policy must be written once further staff are recruited. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 16 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): 33,35 The home is adequately staffed. EVIDENCE: The staff rota was viewed. The duties are currently covered by the owner/manager, and one additional member of staff. This staff member was not present in the home at the time of the inspection. The owner/manager stated that once further service users are admitted to the home, additional staff will be recruited according to their needs. The owner/manager stated that the staff member has undergone moving and handling training, and food hygiene training. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 17 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): 37,42 The home is appropriately managed. EVIDENCE: The owner/manager stated that she has completed her National Vocational Qualification level 4. A bottle of cleaning chemical was found in the toilet. This was immediately locked away by the owner/manager. Window restrictors had been fitted to the first floor windows, in line with a previous requirement. The fire procedure was noted to be listed in each service users bedroom. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 18 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 3 X 3 x Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Malbary House Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000063226.V263713.R01.S.doc Version 5.0 Page 19 no Are there any outstanding requirements from the last inspection? 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. 2. 3. Standard YA20 YA23 YA6 Regulation 13(2) 13(6) 15(1) Requirement Timescale for action 30/11/05 Medication must be stored in appropriate, and correctly labelled containers. The abuse policy must contain all 15/12/05 of the required information. Care plans must be specific, 15/12/05 demonstrate the service users involvement in their writing, and be dated, signed and reviewed. 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 YA9 Good Practice Recommendations A risk assessment should be written in relation to a service user going into the town alone. Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Malbary House DS0000063226.V263713.R01.S.doc Version 5.0 Page 21 - 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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