Inspection on 05/04/05 for Mali Jenkins House

This inspection was carried out on 5th April 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mali Jenkins House 30/08/07

Mali Jenkins House 04/01/07

Mali Jenkins House 30/09/05

Mali Jenkins House 02/09/04

Mali Jenkins House 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Mali Jenkins House The Crescent Chuckery Walsall WS1 2BX Lead Inspector Rachel Higgins Unannounced 5th April 2005 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Mali Jenkins House Address The Crescent, Chuckery, Walsall, West Midlands WS1 2BX 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) 019022 746246 01922 610720 Care first partnerships(BUPA) Miss Gillian Howarth CRH 20 Category(ies) of PD registration, with number of places Mali Jenkins House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1.Age above 40 years Date of last inspection 2nd September 2004 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 placments.The home provides care for service users with neurological illnesses predominately Parkinsons disease.The home is situated just off the main road and is close to a busy bus route,which goes in to 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 adapatations for wheelchair users and people with mobility difficulties.There are 2 assisted bathrooms and one assisted toilet. Mali Jenkins House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on the 5th April 2005.The inspection focused on 11 standards and took 8 hours and 15 minutes to complete. The registered manager Gill Howarth was present throughout the inspection. Information was collated from care documentation, case tracking, staff and service user files and a tour of the building. Two service users and one staff member were spoken during the inspection. What the service does well: Service users find the lifestyle in the home matches their expectations and preferences and their social and recreational interests are met. Service users spoken to stated that there were enough activities provided and choices were offered in relation to food, activities, rising and retiring times. The home has an activities coordinator who works 40 hours a week. The activities programme is varied and service users are asked at meetings their preferences in relation to activities. Service users are confident that their complaints will be listened to and acted upon. The home has a clear and accessible complaints procedure. Service users spoken to felt that they could make a complaint if they so wished. Service users feel that their privacy and dignity is respected. Service users said that ‘staff knock on bedroom and bathroom doors before entering’. The home is cheerful airy and clean with no offensive odours. The home has systems in place to control the spread of infection. Gloves, aprons, liquid soap and hand washing facilities were readily available. The home has recently had new carpets fitted in the reception and corridors. New curtains have been purchased for two of the smaller lounges. The home is run with the best interests of the service users in mind. The home holds service user meetings every six weeks where minutes are taken. Service users spoken to attended the meeting. Anonymous questionnaires are sent out yearly to gain service user views. Mali Jenkins House Version 1.10 Page 6 What has improved since the last inspection? What they could do better: The home needs to address the care records to ensure that all assessments are fully completed; care plans are implemented for all assessed health, personal and social needs. Risk assessments are completed for all service users and must include falls, nutrition and tissue viability. Daily notes written by care staff must show continuation of care and service users are to be weighed on a regular basis. The home needs to address the marked flooring in the toilet, bathrooms, dining rooms and lounges. The grab rails and door frames are in need of attention as some are badly scuffed. The laundry floor needs to be re grouted to ensure that it is impermeable to reduce the risk of the spread of infection. Recruitment procedures need to be tightened, the home needs to ensure that there are no gaps in employment history, dates are written on documents when they arrive in to the home and a photo is available of staff members. The registered manager completes a number of internal audits on a monthly basis. These must be recorded to evidence that they have taken place. The home must ensure that all staff receive the required training in infection control, fire awareness, food hygiene, first aid and moving and handling. The inspector would like to thank the manager, staff and service users for their helpfulness and hospitality on the day of inspection. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mali Jenkins House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Mali Jenkins House Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed at this inspection EVIDENCE: Mali Jenkins House Version 1.10 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10 Care records and documentation need improving to ensure that the healthcare needs of service users are identified and met. Service users are treated with privacy and respect. EVIDENCE: Two files were inspected. The initial assessments were not fully completed. Service users plans were only written for the personal care needs of the service user, they did not include the health or social care needs. One service user had diabetes and was registered blind but there were no care plan detailing the action to be taken by care staff with regards to these needs. The service user also prefers her blood sugars to run higher than the normal range. The home must ensure that a written agreement is obtained from the service user and the relevant healthcare professionals regarding this and a care plan is implemented following this agreement. The home does not currently document the date on which the care plans are reviewed. The home on a weekly basis completes an assessment of abilities, which includes areas such as bathing, mobility, dressing, memory and orientation. The files inspected did contain safe bathing, manual handling risk assessments and other risk assessments but these were only being reassessed on a 6 Mali Jenkins House Version 1.10 Page 10 monthly basis. There were no falls risk assessments even though it had been highlighted that the service user was prone to falls and had recently had a fall, which had resulted in a fracture. There were no nutritional or tissue viability risk assessments and weights had not been recorded on a regular basis. There were entries in the resident’s diary regarding health issues but there was no continuation or documentation of the outcome. Service users spoken to stated that they accessed the General Practitioner, dentist, chiropodist and optician and there was evidence in the file to support this. The manager stated that there was also access to the Parkinson specialist nurse. One resident has insulin drawn up by district nurses a week in advance. The home needs to address this as it is not recommended practice. Care plans were filed in a room, which is not locked at all times. The manager has agreed to address this issue and care plans will now be filed and stored in a lockable cabinet. Service users spoken to stated that their privacy and dignity was respected. Staff knock on bedroom and bathroom doors and examinations by healthcare professionals are conducted in service users bedrooms. Service users have access to a telephone in their rooms or a payphone is available for use in the communal area. The staff member spoken to was aware of how to respect service users privacy and dignity as was able to give appropriate examples of this. Mali Jenkins House Version 1.10 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Social activities are well managed, creative and provide daily interests for service users EVIDENCE: Service users spoken to stated that they were able to exercise their choice in relation to food, routines of daily living, leisure and social activities. The home provides a variety of activities, which are organised by the activities coordinator who works 40 hours per week. Activities offered included quiz’s, gardening, art and craft and outside entertainers. Service users spoken to felt there were enough activities offered and enjoyed the quiz’s and exercises. There are church services once a month for service users who wish to attend. The activities coordinator completes an evaluation form after each activity and service users preferences on activities are sought at service users meetings. Mali Jenkins House Version 1.10 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Complaints are handled appropriately and investigated within the timescales. EVIDENCE: The home has an appropriate complaints procedure, which is displayed in the reception. A record is kept of all complaints made and the details of the investigation. There have been three complaints. One complaint was substantiated the other was not substantiated. Both of these were investigated within the timescales. There is currently one complaint, which is on going. The staff member spoken to was aware of the complaints procedure and service users felt comfortable to make a complaint if needed. Mali Jenkins House Version 1.10 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 Service users live in a safe, clean, pleasant and hygienic home EVIDENCE: The home throughout is very accessible for wheelchair users. is safe and meets the needs of the service user. The home has a programme of routine maintenance, which is undertaken by the maintenance man. There is a programme of renewal of the fabric and decoration of the premises. The front garden is partly completed and is due for completion this year. There is a paved patio area to the rear of the building where there is seating for service users to sit. The home has recently purchased new curtains for the lounges at the front of the home and new carpet had been laid in the reception area and corridors. The flooring in the dining room, lounges, toilets and bathrooms need to be addressed as they look worn or are badly marked. Some of the dining and lounge furniture is scuffed in places and looks worn. Grab rails and doorframes are also in need of attention where again they are scuffed and marked. The holder for the clinical waste bin in the toilet needs attention as the corners are sharp and may cause potential injury. Mali Jenkins House Version 1.10 Page 14 The home provides day care placements and needs to undertake an audit to access the impact that this has on resident’s communal space and staffing. The home was clean, hygienic and free from malodours. Hand washing facilities, gloves, aprons, liquid soap, paper hand towels were readily available. Hand washing posters were sited. Clinical waste bags were available. Mops are colour coded and only used once before they are laundered. There were policies and procedures in place for the control of infection. Ten staff have received infection control training. Staff member spoken to was aware of infection control practice. The laundry had tiled floors and walls that need re-grouting to ensure that they are impermeable. The laundry is very small and there is no segregated area for clean and dirty washing, the home has been advised to contact the infection control nurse for further advice. There was no cleaning schedule in place. Mali Jenkins House Version 1.10 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The home provides sufficient number of care hours to meet the resident’s needs. Some areas in the procedures for the recruitment of staff need improvement. EVIDENCE: There are 5 senior care and 15 care staff. The home has between 4 and 5 care staff on duty on an early shift, 4 care staff on a late shift and 2 care staff at night. The home currently has 10 high dependency residents and 9 medium dependency residents, using the residential forum tool the home are providing sufficient staffing levels. A rota is available which shows which staff are on duty. The home is fully staffed in the kitchen, housekeeping and maintenance. There are 2 senior care vacancies. The home currently has 3 care staff with NVQ 3 and 5 care staff with NVQ 2. The manager has NVQ level 4.There are 10 staff currently working towards their NVQ. Three staff files were inspected. Files contained proof of identification, declaration of health, terms and conditions and an application form. Two files contained 2 written references and one file contained 1 verbal and 1 written reference. The files did not contain a recent photo of the member of staff, gaps in employment history had not been explored and the references obtained in one file were different to those written on the application form. Two staff had been employed before the home had received the Criminal Record Bureau check. The commission had not been made aware of this and it was difficult to evidence that the Protection Of Vulnerable Adult check was received before Mali Jenkins House Version 1.10 Page 16 they commenced employment, as there was no date of receipt on the form. There was no comprehensive risk assessment in place. There was no evidence that staff had read the General Social Care Code of Conduct, a copy was available for staff to read in the manager’s office. The home has an induction programme, which all staff complete. Four staff have completed their foundation programme and 3 staff are currently working towards this. The staff member spoken to had completed their induction and foundation training. Staff receive 3 days training per year and training needs are discussed in staff members yearly appraisal. Mali Jenkins House Version 1.10 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, standard 38 was not fully assessed but will be at the next inspection There is a quality assurance tool but improvements need to be made to ensure that the home receives feedback from all the requisite parties. EVIDENCE: The home conducts service user meetings every 6 weeks and anonymous questionnaires are sent out for completion on a yearly basis. Staff meetings are held on a monthly basis and relative meetings are held on a regular basis. The home does not gain the views of other health care professionals and no questionnaires are sent to relatives. Accident, pressure sore and complaints statistics are sent monthly to head office for analysis. The manager conducts her own internal audits but currently not all of these have been documented. Service user views are published and the results are displayed on the notice board. Service users are made aware of announced inspections and the report was visibly displayed. The home uses a quality assurance tool developed by Mali Jenkins House Version 1.10 Page 18 BUPA, which is still in the development stage which involves annual internal audits. The service users spoken to attended the service user meeting. The home has a manual handling trainer but it was disappointing to see that only 9 staff had completed their training. 7 staff had completed First aid training 11 staff had completed food hygiene 10 staff had completed infection control The home trains staff in house on fire awareness. This is taught by the deputy manager who has undergone a one day training course. These sessions are taught on a one to one basis or in small groups. The home must ensure that there is evidence of the contents of the course delivered at each session. Fire drills are being undertaken but not on all of the shifts. The home is due another fire drill this month as the last one was 27/10/04. Staff are to undergo nutritional training and continuous teaching takes place in house on Parkinson’s disease. Staff would benefit from undergoing diabetic awareness training, as there are service users with diabetes. Mali Jenkins House Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x x x x Mali Jenkins House Version 1.10 Page 20 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. 1. Standard OP7 Regulation 14 Requirement The registered manager must ensure that a comprehensive assessment is completed for all service users The registered manager must ensure that care plans are implemented for all assessed needs The registered persons must obtain a written agreement with regards to JR blood sugar levels and a care plan is written and implemented. The registered manager must ensure that care plans are reviewed monthly and the date documented Care plans must be stored securely and locked The registered manager must ensure that the home has the appropriate risk assessments The registered manager must ensure that service users are weighed on a regular basis The registered manager must ensure that daily records show continuation of care All staff must receive accredited administration of medication training (previous timescale of Version 1.10 Timescale for action 10/4/05 2. OP7 15(1)(2) schedule 3 (3)(m) 10/04/05 3. OP7 15 2(b)(c)(d) 10/04/05 4. 5. 6. 7. OP8 OP8 OP8 OP9 13(4) 13(4)( c),12(a) 17(3)( a) 13(4)(c ) 13(2) 10/04/05 10/04/05 10/04/05 Not met 30/5/2005 Mali Jenkins House Page 21 8. 9. 10. OP19 OP19 OP19 12(a),14( 4)(a) 23 23 11. 12. OP19 OP19 23 23 18,23(2) 13. 14. OP26 OP26 13(3)13(b ) 13(3) 15. OP28 18 16. OP29 sch 2,19 2nd september 2004 The registered manager must ensure that prefilling syringes with insulin is discontinued and a more appropriate and safe method is used. The registered persons must replace the clinical waste holder in the toilet The registered persons must replace the flooring in the small lounges The registered persons must address the marked bathrooms,toilet and main lounge and dining room flooring The registered persons must address the scuffed and marked grab rails and door frames The registered persons must address the scuffed and worn dining room and lounge chairs The registered persons must assess the impact on communal space and staffing that day care placements have.The outcome of this audit must be forwarded to the CSCI. The registered person must gain advice from the infection control with regards to the laundry The registered person must address the laundry flooring and put in place a laundry cleaning schedule. The registered person must ensure that a minimum ratio of 50 trained members of care staff to NVQ level 2 or equivalent is achieved by 2005 (previous requirement) The registered person must ensure that all gaps in employment history are explored and the date in which the POVA check is received is documented and a photo of the staff member is available Version 1.10 30/05/05 30/08/05 30/08/05 30/08/05 30/08/05 30/4/05 30/04/05 30/04/05 Part met 01/09/05 10/04/05 Mali Jenkins House Page 22 17. 18. 19. 20. 21. OP 33 OP38 OP38 24(1) 18(a),13( 5) 13(4) 23(4(d) The registerd manager must document all internal audits undertaken The registered person must ensure that all staff receive mandatory training The registered persons must ensure that fire drills cover all of the shifts 30/04/05 30/04/05 10/04/05 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. 2. 3. Refer to Standard OP29 OP38 OP29 Good Practice Recommendations All staff sign to say they have read the General Social Care Code of Conduct Staff receive diabeties awareness training The registered person must ensure that the CSCI is informed when staff are employed on a POVA first and that a comprehensive risk assessment is completed. Mali Jenkins House Version 1.10 Page 23 Commission for Social Care Inspection Mucklow Office Park, West Point Mucklow Hill Halesowen West Midlands B62 8DA 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 Mali Jenkins House Version 1.10 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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