Inspection on 25/07/05 for Malbary House

This inspection was carried out on 25th July 2005.

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

Malbary House 08/06/06

Malbary House 02/11/05

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 45 Carlton Street Kettering Northants NN16 8ED Lead Inspector Sarah Smart Unannounced 25 July 2005 14.00 th 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 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 Stationary 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 D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Malbary House Address 45 Carlton Street Kettering Northants NN16 8ED 01536 312398 Telephone number Fax number Email 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 3 Category(ies) of LD(E) Learning Disability - Over 65 Years (1) registration, with number LD Learning Disability (3) of places Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedrooms 1, 2 and 3 will be registered initially until the required works has been carried out to an acceptable standard on the remaining three rooms. Date of last inspection N/A Brief Description of the Service: The home currently provides accomodation for three service users in the category of Young Adults, Learning Disability. The owner/amnager has applied to increase the registration to 6 service users now that the refurbishment has been completed. The accomodation 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 D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 2pm and 4.45pm. Preparation for the inspection included review of the last report, and took approximately 1.5 hours. 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 inspection also included a tour of the premises in order to register the additional three rooms, in order that further service users can move into the home. The following areas were covered during the inspection: case tracking, medication, staff rota, staff files, quality assurance, staff supervision, accident records, previous requirements made, and service user interviews. One service user was case tracked. All three service users were spoken to by the inspector. What the service does well: Service users assessments and care plans were written to an acceptable standard. The contracts of residency adequately advised the reader. Service users stated that their needs are met, and that they are happy living at the home. Risk assessments were recorded for the individuals, and there was evidence that healthcare professionals had been consulted appropriately. Medication was managed satisfactorily. The recruitment practice demonstrated safe processes. The environment of the home was very well maintained. The owner has had all of the required checks carried out on the premises i.e. rewire, and gas certificate. Service users had been involved in the choice of décor, and stated that they were happy with their rooms. The home was clean and tidy. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 6 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. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,5 Prospective service users undergo a thorough assessment prior to admission into the home. EVIDENCE: The statement of purpose was viewed in order to ensure that it incorporated information about the additional bedrooms. The document did not advise the reader that one bedroom is slightly below the required size, albeit approved by the Commission for Social Care Inspection. The owner/manager stated that this information will be added. The service users file viewed contained a thorough assessment which incorporated information in relation to the meeting of his needs. Service users spoken to indicated that their needs were met. A sample of a service users contract was viewed, and noted to contain all of the required information. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 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 standard(s) 6,9 Service users needs and choices are identified and met. EVIDENCE: The care plans belonging to the service user case tracked gave adequate information to the reader about the meeting of the service users needs. There was no evidence that the service user was involved in the writing of the care plan. Risk assessments were included in the service users file, and contained adequate information. Further risk assessments were required in relation to the premises of the building which will be addressed fully in standard 41. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 10 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 standard(s) These standards were not assessed on this occasion. EVIDENCE: These standards were not assessed on this occasion. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 19,20,21 Service users are adequately supported in personal and health care. EVIDENCE: Records demonstrated that appropriate referrals are made to healthcare professionals, when required. A sample of medication was viewed. Storage, administration, recording and management of medication was all satisfactory. One service user does not have a next of kin. The manager has recognised the need for the involvement of an advocate to ensure that his wishes in the event of his death are met, and the writing of a will. A death policy was available. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 22 partially The complaints handling process was acceptable. EVIDENCE: The manager stated that she has not received any complaints since the last inspection. A complaints policy is available. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 24,25,26,27,28,29,30 The environment of the home is fit for purpose. EVIDENCE: The facility is very homely. All areas of the home are accessible, and hand rails and grab rails have been fitted in some areas. The garden has been made safe, ahead of being landscaped further in the future. The service users stated that they are happy with their bedrooms. The owner/manager advised that the service users had been involved in the choice of décor, and rooms were personalised by the individual occupying it. The home has a new shower room on the first floor, plus a fitted bathroom. On the grounds floor is a cloakroom, plus a walk in bath with shower. New flooring was being fitted to these areas at the time of the inspection. The home has a large lounge/diner, a smoking lounge, kitchen, and utility. The home has had a call bell system installed, however there is not a call facility in the shower room, and the call can be reset by staff without visiting the service user requiring assistance. A risk assessment and policy is required in relation to these issues. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 14 A great deal of work has been undertaken in the home since the initial registration, and the three further bedrooms are considered ready for occupation. The home was clean and tidy at the time of the inspection. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36 Staffing is appropriate to meet the needs of the service users. EVIDENCE: The home currently employs one staff member, whose file was viewed. No further staff had been employed since the last inspection. The rota indicated that all of the care shifts are covered by the owner/manager or this staff member. The owner/manager stated that provisions are made should either of the two staff require time off work. The manager demonstrated that recruitment processes were in place, once registration of the additional rooms is granted, to safely employ further staff at the home. Records in the staff file indicated that the staff member is supervised regularly, and receives regular appraisal. A previous requirement was made in relation to recruitment of staff. Whilst the existing staff members file did not contain an application form, the manager reassured the inspector that application forms would be sent to all applicants for future posts. A copy of this application form was viewed. Therefore this requirement has not been restated. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,42 The home is appropriately managed. EVIDENCE: The staff member, and the service users stated that the owner manages the home appropriately. The manager said that she is soon to complete her NVQ level 4 qualification. At least one wash hand basin did not have hot water supplied at a guaranteed safe temperature. The manager advised that she has recently had a new boiler installed, and understood that this is managed at source from the boiler. The manager must check this detail, and in the interim carry out a risk assessment in relation to service users burning themselves. Some of the first floor windows were not restricted in the amount they open. The manager demonstrated that such restrictors had been fitted in some areas. The manager must either fit such restrictors throughout, or carry out a risk assessment in relation to this. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 17 The manager added that the home has recently been completely rewired, and a certificate has been obtained for the gas installation. A health and safety inspection had been undertaken, and recommendations carried out. Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 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 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Malbary House Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x 2 x x D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 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. Standard 28 Regulation 12(1) Requirement A risk assessment must be carried out in relation to the lack of call bell in the first floor shower room, and identified action taken. A policy must be written in relation to the ability to cancel call bells without the staff member attending to the service users requiring assistance. A risk assessment must be carried out in relation to the supply of hot water, and identified action taken. A risk assessment must be carried out in relation to the unrestircted opening of first floor windows, and identified action taken. Timescale for action By 20.8.05 2. 28 12(1) By 20.8.05 3. 41 12(1) By 20.8.05 4. 41 12(1) By 20.8.05 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 19 Good Practice Recommendations Care plans should evidence involvement of the service user in their writing. D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 20 Malbary House Malbary House D C51 C08 S63226 Malbary House V240944 250705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. 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