CARE HOMES FOR OLDER PEOPLE
Mali Jenkins House The Crescent Chuckery Walsall West Midlands WS1 2BX Lead Inspector
Mrs Wendy Grainger Key Unannounced Inspection 30th August 2007 09:00 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 Mali Jenkins House DS0000020817.V342436.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. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Mali Jenkins House Address The Crescent Chuckery Walsall West Midlands WS1 2BX 01922 746246 01922 610720 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) www.bupa.co.uk BUPA Care Homes (Partnerships) Limited John Grooms Housing Association Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Age above 40 years Date of last inspection 4th January 2007 Brief Description of the Service: Mali Jenkins is a detached property that was originally built for use as a sheltered housing complex. The home provides 20 single rooms, all of which are ensuite. The home also offers respite and day care placements. The home provides care for service users with neurological illnesses predominately Parkinson’s Disease. The home is situated just off the main road and is close to a busy bus route, which goes into Walsall Town centre. There is off road parking at the front of the property with a small garden to the rear. All rooms and communal areas are on the ground floor. The home is well laid out with adaptations for wheelchair users and people with mobility difficulties. There are 2 assisted bathrooms and one assisted toilet. From the information provided on the day of the inspection by the management the current fees were £445 & £750 Additional extras purchased privately would include hairdressing, private chiropody, and personal toiletries. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was unannounced and completed in one day by Mrs W D Grainger Inspector. The commission had received the homes annual quality assurance assessment plus four “have your say” forms provided by the people who use the service about their experience of the home and service provided. Several of the people who use the service were spoken with during the day and staff were observed in their work practices, which included the medication system. A sample of the files both for people who use the service and for the staff were made available to the inspector. The inspection included a tour of the home, documents, records and reports including contractual servicing of equipment, staff qualifications, experience and training were examined. At the time of this inspection there were twenty people who use the service at Mali Jenkins, each of the people who use the service had some degree of a physical disability, there was a range of ages from 52 years to 91 years of age. On the day of the inspection the home had two people who came to the home for day care. Evidence in the “have your say “ forms provided the inspector with a small overview of the homes admissions process and the experience of people who use the service. “Due to circumstances no other home was considered” “ I know who to speak to if I have a problem” “very good care and support from members of staff anything I need I receive” “kindness and support is given to me”” Staff listen to me and act on what I say” “ I hope that we could do more activities having days out would be nice” “ the care is excellent and I feel very happy” a number of these comments were reflected by other people on the day. There were plans to provide better facilities in the two small lounges and to possibly create a treatment room from one of the bathrooms not in use. At the time of this inspection Mali Jenkins was without a registered care manager. The prospective manager is to attend an interview with CSCI on the 4th September in Birmingham. What the service does well: Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 6 This was the inspectors’ first visit to the home. Located in a quiet area near to shops and a public house, the home offers a comfortable environment suitable to meet individuals needs, the home was spacious, well decorated with quality furnishings and fittings. Individual and collective equipment was available to assist and promote the independence of people where possible. The staff and management worked as a team each one aware of the needs of individuals enabling them to continue their life style. Residents provided the inspector with comments in their returned“ have your say” forms which included “ I am happy with the care and support I receive here” “ the staff are very helpful towards me If I have any problem they will act on my behalf” “staff help me to play bingo I like the memory game which keeps my brain working” “ I like the meals but would wish to have smaller portions as I am not a big eater” “I would know who to talk to if I have a problem” “I feel at home here” Staff were observed to be supportive and sensitive to the daily routine of the people who use the service. The inspector observed staff, including one of the housekeeping, knock on bedroom doors and wait to be asked in thus respecting individual’s privacy and rights. The housekeeping staff were complimented on the high standard of hygiene observed throughout the home. . What has improved since the last inspection? The staff had commenced the new care planning system “Quest” all the care staff and activity person were involved. New staff had been employed following in line with safe recruitment practices and had undergone the necessary checks. The home had recently had a new water tank installed. The home had recently received a grant to spend on planned improvements within the home. From the information in the annual quality assurance assessment there had been some changes to the homes documentation, training for the staff to
Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 7 complete the documents continued as did the on going re-decoration programme 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. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 8 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 Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good, Standards 1, 3,4, were reviewed This judgement has been made using available evidence including a visit to this service. No person is admitted to the home without a full assessment of his or her personal and health needs. The Statement of Purpose contained the appropriate information that would enable a person to make an informed choice about the home. EVIDENCE: The home had a comprehensive assessment format evidenced in the care plans seen. No person was admitted into the home without this full assessment of his or her health, personal and physical needs. Since the previous inspection records evidenced that a letter confirming the placement was sent out to the individual person. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 10 The home had a colourful brochure providing information about the company, home and location. This coupled with the Statement of Purpose would enable any person to make an informed choice. The most recent admission had experienced respite care previously. The person had made a decision to live permanently at Mali Jenkins. The plan of care clearly detailed that at the time of admission his health and personal needs could be met. The plan identified the transition from respite to permanent care with all parties involved in the placement being recorded. This person told the inspector “it was a difficult decision but I am happy and settling in” Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good, Standards 7,8,9,10 were reviewed This judgement has been made using available evidence including a visit to this service. A comprehensive plan of care ensured that the required needs of individuals were met on a daily basis. Arrangements were in place for the continued health care by other professional agencies. The medication system was robust and ensured via the training programme it protected the people who use the service. Staffs on duty were responsive and met the daily needs of individuals, in a sensitive manner; they were observed to promote independence at all times. EVIDENCE: Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 12 A sample of three people who use the service were case tracked this included checking their medication and with speaking to people who use the service. Each of the plans of care was detailed and identified a person’s routine. Within the plans there was evidence that other professional agencies had been contacted when applicable. Care plans were reviewed monthly, recorded and dated. There had been a problem with the files containing the plans but this appears to have been rectified and the documents were now held more securely in the modules. Risk assessments were recorded and were applicable to the needs of people based on the care plans seen. The “Quest” programme was a rolling programme by the company to promote staff awareness and a responsibility to record on individuals plans as a “daily life diary”. These diaries were concise, informative and provided valuable details of the shift and needs addressed. Another system within the care plans was the “must” tool where, when applicable, each individual had a nutritional and weight chart completed by the staff, which reflected their health changes. All the senior care staff including the night staff had received training in the administration of medicines. The medication system was observed; the senior on duty had been delegated to take full responsibility for the system including ordering and returning medication; plus a weekly audit. The person spoken with was knowledgeable about the system and demonstrated that she was fully aware of the need and reasons why medication was prescribed. Because of the nature of individuals conditions medication could, with agreement of all parties, be administered at a time to suit the needs of the individuals. The records were well maintained by all the staff responsible. During the day the staff on two shifts including the activity co-ordinator was observed, they interacted well with the people who use the service. Light banter was heard between people who use the service and the staff. Each person was treated with respect and dignity; they were assisted where applicable. Staff were pleasant and knowledgeable about the client group. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good, Standards 12,14,15 were reviewed This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged to partake of the positive social life on offer at Mali Jenkins. The menus contained a well balanced diet of a nutritional content. Visitors were welcome to visit the home at any time suitable to them. EVIDENCE: From the records, discussions with the activity co-ordinator and observations during the day, it was obvious that people who use the service had the option to partake in any of the in-house activities. The home had the use of a vehicle unfortunately a resident told the inspector it was not used as much as they would like. Certain people would like to go out more, as commented in the “have your say” form “I would like to go into the community more and do day trips”.
Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 14 One of the people who use the service was an accomplished artist who displayed her work throughout the home. Staff interacted with the people who use the service, the nails of one person were trimmed and painted after lunch, a number of the ladies had their hair done each one had a pleasing result. Outside entertainment was provided on a regular basis, the inspector was told that this form of activity was enjoyed. Where possible individuals were encouraged to control their life style. From the “have your say “ forms individuals were aware who to speak to in the event of a concern. “ the staff listen to me” “ I join in the activities and enjoy the memory games it keeps me alert” “ I have to have some help with Bingo because my eyes could be better” From the menus provided, which were maintained in a neat orderly manner the records of food provided, displayed a balanced nutritional diet. Menus offered an alternative for each meal served. The dining room was set in a pleasing style that made meals a social event. Two meals of the day were observed each one was well presented in a professional manner. The inspector sampled the tasty home made soup a choice also made by some people who use the service. At the time of the inspection no special meals or diets were prepared. The home had no vegetarian people who use the service despite the comments in the “have your say” form Comments from the people who use the service and spoken with at the time of the inspection were positive in respect of the meals.” I always like the meals” “ sometimes I like the meals apart from certain meals which I ask for a change” “ I would like more variety in the sweets and more vegetarian meals” “ I sometimes would like a smaller portion” The kitchen while small in design was well equipped and maintained. The chef had the relevant qualification to cater for the people who use the service. He is qualified and trained to complete supervision of his staff and has a number of years experience in the catering profession. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good, Standards 16 18 were reviewed. This judgement has been made using available evidence including a visit to this service. The complaints procedure was contained in the relevant documents provided to people who use the service and families. Staff were aware of the need, via training, to protect the people who use the service from any form of abuse. EVIDENCE: The commission had received no complaints about the home or care it provides. The manager had dealt with one complaint raised with her recently. The records demonstrated that the manager had addressed the issue to the satisfaction of the complainant. The process of dealing with the complaint was within the given timescale of 28 days. Records provided evidenced that the staff had received training/knowledge for the protection of vulnerable adults. This was confirmed by three of the staff spoken with during the day. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 16 On the notice board there were thank you cards from grateful relatives where the home had provided kindness and care during a respite stay. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good, Standards 19 20 21 23 24 26 were reviewed. This judgement has been made using available evidence including a visit to this service. The home provided a comfortable environment to meet the needs of people with complex needs. The people who use the service experienced an odour free environment, which was well maintained. EVIDENCE: The environment was a credit to the housekeeping staff. Egress and access to the small garden area at the rear was suited to the client group. The home has a rolling programme for the redecoration and refurbishment of the home.
Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 18 The manager had plans to re carpet 8 bedrooms and the lounge in the near future. Within the next years project and expenditure armchairs in the lounge will be renewed. It was agreed with the CSCI’s Central Registration Team on the day of the inspection and based on the needs of the people who use the service, that one of the bathrooms would be better re-designed and used as a treatment room and hairdressing salon. Each of the bedrooms had a full size shower suitably equipped and easily accessed by the people who use the service. From the sample of bedrooms seen at the time it was obvious that individuals were encouraged to personalise their private space. Each of the doors were fitted with a lock, some people who use the service choose to have their door locked when they go out. The lounge dining room was central to the home; tables were pleasant in their presentation The small but well equipped kitchen was off the dining room, the home had received a clean kitchen award in 2007, plus recognition of the high standards maintained in previous years. The homes water tank had to be replaced this year before any problems occurred. The manager has received a grant to be spent on a project for the home. At each end of the home there was a small lounge area, which were to be part of the planned project to refurbish and redecorate making the areas more homely. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate Standards 27,28,29,30 were reviewed. This judgement has been made using available evidence including a visit to this service. There appeared to be adequate numbers of staff employed to meet the needs of the people who use the service. Night staff arrangements should be reviewed to ensure service users have a choice in relation to the gender of their carers. Staff were receiving training but the records were inconclusive to determine the overall training provided. EVIDENCE: The training record matrix was out of date, the home has been without a deputy manger who as part of her role maintained the matrix. Staff spoken with confirmed that they had received the required mandatory training. Records identified that all the staff were trained for Moving & Handling, infection control; the housekeeping staff had COSHH training. One of the senior staff had recently undertaken a course for dementia awareness, the home is not registered for this condition, some of the people who use the service are of mature years. This training will be cascaded to the other staff as
Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 20 part of the homes in-house training. National Vocational Qualifications levels II & III were on going. The care manager and one other staff were without a current first aid qualification, this should to be addressed as soon as possible; there were however sufficient staff on duty including the nights that had the qualification. The homes recruitment programme for the employment of new staff was robust, the records evidenced that all the procedures for checks including a criminal record check prior to employment were satisfactory. The inspector had concerns that while there were two waking night staff on duty, they were both male members of staff. This arrangement is not conducive to offer choice for the people who use the service when they prefer not to have male carers. This was discussed with the manger and advised that this should be reviewed to consider a change. There were sufficient numbers of staff on duty at the time of the inspection to meet the daily life style of the people who use the service. Staff during the visit worked as a team to enable people who use the service to lead a normal life style. The home was without a deputy care manager, and administrator, the home did not use agency staff and there were no vacancies for staff at the time of the inspection. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good Standards 31 33 35 38 were reviewed. This judgement has been made using available evidence including a visit to this service. The home operates for the benefit of the people who use the service the ethos was pleasant and relaxed. The best interests of the people who use the service were promoted by the policies and procedures for health & safety. EVIDENCE: Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 22 The prospective care manager had an interview arranged by the Commission for the week following the inspection. She had recently completed the Registered Mangers Award; her experience had been over a number of years in residential care including time spent at Mali Jenkins, she also has the A1 & A2 award. One of the people that had been trained to supervise staff had left employment. The prospective care manger has commenced this process. It is important that this process continues and maintained as a rolling programme six times each year. A sample of the finances held on behalf of the people who use the service were checked and found satisfactory. The records checked for the practice and procedures for fire were satisfactory the only comment made to the manager was that she should encourage staff to personally sign for training for fire drills and any other in-house training. The manager had contingency plans in place for the home, in the event of an emergency. Other records checked corresponded with the information contained in the annual quality assurance assessment document. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 23 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP30 Regulation 181 (c) Requirement The responsible person shall ensure that the staff employed are trained appropriately for the work they are to perform Timescale for action 01/10/07 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. Refer to Standard OP27 OP38 Good Practice Recommendations To review the night staffing arrangement to ensure all the choice of the people who use the service needs are met. To consider staff signing as individuals following any inhouse or fire drill training. Mali Jenkins House DS0000020817.V342436.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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
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