Inspection on 08/06/06 for Malbary House

This inspection was carried out on 8th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Malbary House 02/11/05

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 8th June 2006 09:30 DS0000063226.V298208.R01.S.doc Version 5.2 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 DS0000063226.V298208.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 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. DS0000063226.V298208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Malbary House Address Malbary House 45 Carlton Street Kettering Northants NN16 8ED 01536 481708 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) N/A Mrs Jacqueline Mary Miller Mrs Jacqueline Mary Miller Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000063226.V298208.R01.S.doc Version 5.2 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 exceed 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. 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. Fees currently charged at the home are £450 per week. DS0000063226.V298208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An announced inspection was undertaken between the hours of 09.30 and 12.30. The owner manager was informed of the planned inspection to ensure that service users and staff were at the home at the chosen time. Preparation for the inspection included, review of the previous inspection report, requirements and recommendations, and service history, and took approximately 4 hours. Written feedback in the form of questionnaires was received from three service users, and two relatives. All of the feedback received was positive. 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 files, quality assurance, staff supervision, accident records, complaints records, sample tour of the premises, previous requirements made, and staff and service user interviews. Two service users were case tracked, and were selected as they were the service users at home at the time of the inspection. One staff member, plus the manager, were spoken with at length, whilst three service users were spoken with in detail. What the service does well: Thorough needs assessments were recorded, and service users needs were being met. Service users reinforced this, and said that they are offered choices about their daily lives, and do not feel unnecessarily restricted. They added that their privacy and dignity is respected, and that the food is nice. Risk assessments seen were recorded to a high standard. Service users are encouraged and enabled to partake in activities within and outside the house, and to be as independent as possible. Service users are enabled to have consultations with members of the multidisciplinary team. Medication was stored and recorded satisfactorily. The complaints policy was satisfactory, and staff knowledge of this was adequate. The premises of the home were satisfactory, and service users were happy with their rooms. DS0000063226.V298208.R01.S.doc Version 5.2 Page 6 Staff files contained all of the required information, and staffing levels were adequate. Quality monitoring was carried out, and feedback from service users and their relatives was positive. Fire records were adequately recorded. 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. DS0000063226.V298208.R01.S.doc Version 5.2 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 DS0000063226.V298208.R01.S.doc Version 5.2 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 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Service users needs are assessed and met. EVIDENCE: A sample of service users files were viewed. Each file contained a thorough needs assessment, covering physical and mental health needs. From observing care practices and documentation during the inspection, and speaking to staff and service users, the inspector was satisfied that service users needs are met. DS0000063226.V298208.R01.S.doc Version 5.2 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 Quality in this outcome group is adequate. This judgment has been made using available evidence, including a visit to the service. Individual service users are able to make choices about their daily lives without being unnecessarily restricted. EVIDENCE: Care plans belonging to two service users were viewed. Both of these documents contained clear instruction to staff, as to how the service users needs were to be met. This meets a previous requirement. The care plans did not evidence the service users involvement in their writing, however the manager stated that they had been discussed. It is recommended that this discussion is recorded. The care plans were not dated, signed, or reviewed timely. Service users spoken to stated that they are allowed to make choices about daily lives, and are involved in decision making. Each service users file contained thorough risk assessments in all but one instance. It is recommended that a further risk assessment is recorded for one of the service users case tracked in order to ensure her safety. DS0000063226.V298208.R01.S.doc Version 5.2 Page 10 Service users stated that they do not feel unnecessarily restricted. DS0000063226.V298208.R01.S.doc Version 5.2 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): 12,13,15,16,17 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Service users are enabled to lead fulfilling and lifestyles which are as independent as possible. EVIDENCE: None of the service users are currently involved in education, or employment. three of the service users regularly attend a local day centre. Service users spoken to stated that they visit the local shops and town, either independently or accompanied by staff according to their risk assessments. They added that they are able to maintain links with friends and family. All of the service users had been to the zoo several days before the inspection, which they spoke positively about. One service user was supported by the home to form relationships with people outside the home. Service users advised the inspector that their privacy and dignity is respected by the staff, and pleasant communication was noted during the inspection. DS0000063226.V298208.R01.S.doc Version 5.2 Page 12 The service users also gave positive feedback about the food supplied in the home. One service user said that she partakes in the preparation of food. DS0000063226.V298208.R01.S.doc Version 5.2 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): 18,19,20 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Service users are adequately supported in terms of personal and healthcare. EVIDENCE: The inspector was advised by the manager that community nurses provide support in the home, and records reinforced this. There was evidence that service users access members of the multidisciplinary team as necessary. Healthcare assessments are not recorded for the service users, however their weight was regularly recorded. A sample of medication was viewed. The storage and recording was all satisfactory, meeting a previous requirement. DS0000063226.V298208.R01.S.doc Version 5.2 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): 22,23 Quality in this outcome group is adequate. This judgment has been made using available evidence, including a visit to the service. Complaints and allegations of abuse would be appropriately handled despite the policy which should be updated to ensure protection of service users. EVIDENCE: The complaints policy was satisfactory. The home have not received any complaints since the last inspection. Staff spoken to had an adequate knowledge of the complaints process. The protection of vulnerable adults policy had not been reviewed, despite this being the subject of a previous requirement. The manager assured the inspector that she would obtain the correct documentation that afternoon. Staff spoken to during the inspection demonstrated a good knowledge of the procedure to be followed following an allegation of abuse. DS0000063226.V298208.R01.S.doc Version 5.2 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): 24,30 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. The premises of the home are suitable to meet the service users needs. EVIDENCE: A sample tour of the premises was undertaken. All areas viewed were clean and tidy, and maintained to an acceptable standard. Service users spoke of being happy with their rooms, and were involved in the choice of decor etc. The home has an attractive garden which is accessible to service users. DS0000063226.V298208.R01.S.doc Version 5.2 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): 32,34,35 Quality in this outcome group is adequate. This judgment has been made using available evidence, including a visit to the service. With the exception of training, all areas relating to staffing were satisfactory, meaning that the service users needs are met. EVIDENCE: A sample of staff files were viewed. These were maintained to an acceptable standard, and contained all of the required information. Staffing levels were adequate. Staff training was in need of updating in several areas, which the manager recognised. She stated that such training would be arranged during the coming months. DS0000063226.V298208.R01.S.doc Version 5.2 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): 37,39,42 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. The home is appropriately run and managed in the best interests of the service users. EVIDENCE: The manager has completed her NVQ level 4 training, and manages the home to an acceptable standard. Quality monitoring is undertaken twice yearly and feedback from the most recent survey was all positive. The feedback received by the inspector was also positive. The manager should consider writing a quality assurance policy. Fire records were all maintained up to date. There have been no accidents in the home since the last inspection. The home have not undertaken Portable Appliance tests, and it is recommended that these are carried out over the coming months. DS0000063226.V298208.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 x DS0000063226.V298208.R01.S.doc Version 5.2 Page 19 yes 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. 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. 2 3 4 5 Refer to Standard YA23 YA6 YA9 YA35 YA42 Good Practice Recommendations The abuse policy should contain all of the required information. Care plans should evidence the service users involvement in their writing, dated, signed, and reviewed timely. A risk assessment for an identified service user should be recorded in connection to relationships. Staff training should be updated as soon as possible. Portable Appliance tests should be carried out. 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