Inspection on 18/04/05 for Malmesbury House

This inspection was carried out on 18th April 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

Malmesbury House 25/08/09

Malmesbury House 29/08/08

Malmesbury House 30/08/07

Malmesbury House 15/05/06

Malmesbury House 02/11/05

Malmesbury House 11/01/05

Malmesbury House 20/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Malmesbury House 18 Beauchamp Road East Molesey Surrey KT8 0PA Lead Inspector Vera Bulbeck Unannounced 18 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. Malmesbury House Version 1.10 Page 3 SERVICE INFORMATION Name of service Malmesbury House Address 18 Beauchamp Road East Molesey Surrey KT8 0PA 020 8783 0444 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 Mary Gajraj Dr H Gajraj Dr N Gajraj Mrs Mary Gajraj Care home only (PC) 19 Category(ies) of Physical disability over 65 years of age (PD(E)), registration, with number 2 of places Old age, not falling within any other category (OP), 2 Dementia - over 65 years of age (DE(E)), 14 Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)), 1 Sensory Impair over 65 SI(E), 1 Malmesbury House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: (14) service users in category DE(E) (Dementia - over 65 years of age) (1) named person may also fall within category SI(E) (Sensory Impairment over 65 years of age) (2) Physical disability over 65 years of age (2) Old age, not falling within any other category Date of last inspection 11 January 2005 Brief Description of the Service: Malmesbury house is a large detached property situated in a residential area close to the local shops of West Molesey. The accommodation is on three levels, ground floor, first floor and second floor. All floors are accessible by a passenger lift. The majority of the bedrooms are of a good size, and are single bedrooms with en-suite facilities. A number of service user’s bedrooms situated on the ground floor have access to the garden. The home is set in spacious and well-maintained grounds, which are readily accessible to the service users. There is a large nicely furnished conservatory used by service users mainly for activities. The conservatory is also used, as a quiet area for service user’s to entertain relatives and friends. There is ample car parking at the front of the premises. Malmesbury House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Vera Bulbeck, Lead Inspector for the service, carried out the inspection. Mrs Mary Gajraj, Registered Manager/proprietor, was present as the representative for Malmesbury House. The home is registered for nineteen places. There are currently thirteen service users living in the home. A full tour of the premises was undertaken. Three care plans were observed and three staff files were inspected. Four members of staff were spoken with during the inspection as well as thirteen residents and two relatives. What the service does well: The home has a statement of purpose and service users guide which sets out the aims an objectives and facilities of the home The home has a stable and committed staff team. Some staff commented they are supervised and supported and are able to speak with management at any time. The inspector spoke with thirteen residents who gave positive feedback with regards to the care they receive and stated that the staff are kind and helpful. One service user stated, “The home and staff are very good”. A number of residents were unable to communicate well and the inspector observed the interaction between staff and service users to be good. A member of staff was sitting painting service users nails, which was clearly enjoying the attention received. Malmesbury House Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Malmesbury 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 Malmesbury 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) 1,3,4,5 and 6. The admission procedure to the home should ensure that there is a proper assessment prior to people moving into the service. Without an assessment there is no assurance the care needs will be met. EVIDENCE: The home has produced a comprehensive statement of purpose, which, has been updated to include the services the home provides, and a copy is provided to all new residents as well as a copy of the service users guide. The document contains all the relevant information and is service user friendly. Residents were very complimentary about the care they received and commented the home met their needs. A relative also commented on the home being able to meet the needs of his mother. However, the son stated his mother has not been living in the home for long and is still in the settling in stage. Assessments of residents need to be updated and appropriately documented to record details of residents. An assessment needs to be undertaken on one new resident. Assessments should be undertaken before the resident moves into Malmesbury House Version 1.10 Page 9 the home to ensure the home is able to meet the needs of the resident. Where possible, residents should be involved in the assessment process and if they wish their relatives/friends views to be taken into account. Prospective residents are encouraged to visit the home to have a look around, have lunch and talk with existing residents. The service provides the potential resident a trial period of six weeks, however this period of time may be extended if requested. The home does not provide intermediate care. Malmesbury House Version 1.10 Page 10 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) 7,8,9 and 11. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are now in place to ensure the safe administration of medication. EVIDENCE: A care plan needs to be in place on the day of admission to ensure the staff are able to offer the care required as part of the care plan. Residents and family should be involved with care planning. Full details of the residents, need to be documented on the care plan including residents wishes in the event of their death. The home informed relatives of any deteriorating change to the resident’s health and maintains the dignity and privacy of residents. Relatives are invited to stay with their relative for as long as they wish. The home has clear policies and procedures in place. Malmesbury House Version 1.10 Page 11 The admission procedure was not being followed and is not adequate to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned. The inspector spoke with a relative who stated that he was satisfied with the care his mother received. However, he did say his mother gets bored and spends a lot of time in her bedroom. He also commented that his mother is an early riser 4am and likes an early morning cup of tea when she wakes up. He also stated his mother lived in her own home she was able to make herself a drink. There was no record in the residents care plan that she wakes early and would like a cup of tea. Four care plans were inspected and the majority were found to contain letters and details of medical needs. However the recording in the care plans was poor, health care needs must be clearly identified and followed up. There are three residents living in the home who are able to self medicate. Residents must be provided with a lockable facility and bedroom doors must be kept locked by the resident, particularly where and medication left in residents bedrooms for example in a bowl of fruit and in another bowl of sweets. There were no records maintained detailing how many tablets the resident was given, date received or any clear instructions for the resident. An immediate requirement was made to ensure medication is appropriately managed. The Royal Pharmaceutical Society of Great Britain document, The Administration and Control of Medicines in Care Homes and Children’s Services, must be followed at all times. Staff were observed to interact in a respectful manner with residents, particularly those with dementia. Malmesbury House Version 1.10 Page 12 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 and 14. The routines of daily living and activities are flexible and varied to suit individual service users wishes. Service users are encouraged to exercise personal autonomy and choice. EVIDENCE: There are systems in place to involve service users in their daily living, residents choose the clothes they like to wear and inform staff if they require help with dressing. There was evidence of a comprehensive range of activities, which are based upon resident’s capabilities. On the day of inspection there was a class in the afternoon. They have exercise classes as well as the usual bingo and quiz time events. There are no restrictions placed on visitors and those present at the time of the inspection were made to feel welcome by management and the staff. The home has a separate conservatory where residents are able to talk to their visitors in private or they use their bedroom. One relative informed the inspector he prefers to speak with his mother in her bedroom. The home has spacious indoor and outdoor communal areas, social events were held frequently in these areas and relatives and visitors are invited. Malmesbury House Version 1.10 Page 13 The registered manager stated that it was policy not to manage resident’s personal finances. Relatives and representatives or external agents act on their behalf. Access to personal records are facilitated on request in accordance with the Data Protection Act 1998. Malmesbury House Version 1.10 Page 14 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) 16,17 and 18. The home has a satisfactory complaints system that is made available to all relatives and visitors which is displayed in the entrance of the home. EVIDENCE: The home has developed its complaints procedure and has incorporated details of the Commission for Social Care Inspection. The inspector advised the home to provide all residents with a copy of the complaints procedure. A relative commented that if he had any problems or complaints he would speak with the manager to discuss what action would be taken. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and all staff have received POVA training. Staff confirmed they had undertaken this training and were aware of the procedures. Residents are encouraged to vote and have been registered for a postal vote. Malmesbury House Version 1.10 Page 15 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) 19,20,21,22and 24. The home was found to be homely and comfortable. However, there are areas around the home looking tired and in need of decorating, and some furniture needs to be replaced. Some health and safety issues in the home need to be addressed. The location and layout of the home is suitable for it’s stated purpose. EVIDENCE: There were a number of areas around the home requiring attention. A number of bedrooms were without window restrictors, a window catch on the ground floor passageway needs repairing. A number of toilet bowls were badly stained and one toilet was blocked. A number of bedroom curtains were not hanging appropriately. And some carpets were in need of deep cleaning or replacing. In room 10 bathroom the light was not working and in another bathroom on the first floor a fluorescent light needs a cover. Malmesbury House Version 1.10 Page 16 Trailing wires need to be attended to and on the outside fire escape route on the roof of the home, there were trailing wires, ladders laying on the walkway and the walls were crumbling. The kitchen toilet was found to be used as a storage room for papers and a variety of items, which need to be cleared. The laundry was left unlocked and the cupboard under the sink was unlocked which contained tins of paint and cleaning materials. This was made an immediate requirement. The majority of chairs in the lounge are in need of replacing. The inspector advised the home to provide a maintenance book to enable all staff to document areas in need of attention. The book should be signed and dated by the maintenance person when work has been completed. The food storage cupboard needs to be sorted and to be arranged in an orderly manner. The conservatory is light and nicely furnished and is used by residents as a quiet area also to entertain their relatives. The garden is well maintained and secluded and accessible for residents to use. Malmesbury House Version 1.10 Page 17 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) 27,29 and 30. The staff were observed to interact well with the residents and it was apparent that a high degree of respect and skill in working with individual residents at the home. Staffing levels are kept under review and if necessary increase the staffing levels when necessary. EVIDENCE: The home is adequately staffed as agreed and will be regularly reviewed. The home has a part time cook three days a week and every other weekend. The registered manager has been undertaking the cooking on the other days and every other weekend. The inspector advised the manager to employ a cook during this time to enable the registered manager to be more involved with the management duties. The home has a cleaner who is currently off sick; therefore the care staff have been covering these duties. Staff were observed to interact well with the residents. A relative commented that staff were very friendly and kind to residents. Malmesbury House Version 1.10 Page 18 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) 31, 33, 36, 37 and 38. The registered manager/proprietor is supported by staff, in providing leadership in the home with all staff illustrating an awareness of their roles and responsibilities. EVIDENCE: The homes registered manager/proprietor is experienced and has managed the home for a number of years. She needs to complete the Registered Managers Award, and is looking into the process of commencing in the near future. The management of the home was observed to be open and anxious to maintain a positive friendly and relaxed atmosphere. A relative confirmed the management and staff are helpful and commented his mother receives good care. The home needs to undertake a regular quality audit on the premises to ensure items in need of repair and attention need to be addressed. The Malmesbury House Version 1.10 Page 19 inspector advised the management to produce a maintenance book and record work to be undertaken and completed by the maintenance person. Records of staff supervision were observed and the inspector was informed the Deputy Manager has commenced staff supervision and is hoping to complete all staff very shortly. Staff should receive supervision at least six times a year. There is a commitment by the registered manager/proprietor to regular update staff training. Record keeping has much improved and a number of records were observed, these include the accident book in which it was noted that the record needs to be signed and dated by the manager. Fire safety records were well documented and up to date. Health and safety records including certificates were on file and up to date. There is a need to complete a fire risk assessment on the whole premises; the previous record was out of date. All records in the home are held in the main office, which is kept locked when not in use. Staff and residents personal files are kept in a locked filing cabinet. Malmesbury House Version 1.10 Page 20 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 3 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 2 3 x 2 x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x x 3 2 2 Malmesbury House Version 1.10 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Standard 3 7 4 9 9 19 19 19 19 19 Regulation 15 15 14 13 13 13 13 16 13 13 Requirement Care plans must be in place for all new residents on the day of addmission. Care plans must be updated and recording improved. Pre addmission assessments must be undertaken including full details of the resident. Medication policies and procedures must be followed for self medicating residents. All medication must be stored in a locked facility. All windows above the ground floor must have restrictors. A number of toilets require deep cleaning. A number of carpets are badly stained and must be deep cleaned or replaced. Trailing wires in bedrooms and on the landing must be secured. The fire escape route on the roof must be cleared of ladders and trailing wires, and walls must be repaired and made safe. Two catches on windows are broken and must be replaced. Risk assessments must be undertaken on residents who self medicate. Version 1.10 Timescale for action 18/04/05 29/04/05 22/04/05 18/04/05 18/04/05 22/04/05 22/04/05 27/05/05 19/04/05 29/04/05 11. 12. 19 9 23 14 29/04/05 29/04/05 Malmesbury House Page 22 13. 14. 15. 21 21 21 23 23 23 16. 17. 24 27 16 18 18. 19. 20. 21. 37 38 38 38 17 13 13 23 Kitchen toilet to be cleared of items stored, and must be used by the kitchen staff. Room 9 Toilet must be unblocked. Room 10 bathroom light must be replaced and the flourescent light in the bathroom on the 1st floor requires a cover. Curtains hanging off rails require attention. The registered manager to be more involved with the administration of the home and should cease cooking (Timescale 15/02/05 not met). The accident book must be signed and dated. A fire risk assessment to be completed on the whole of the premises. All cleaning materials must be stored in a locked facility at all times. The food storage cupboard needs to be stored in an appropriate manner to enable food to be used in date order. 22/04/05 19/04/05 22/04/05 29/05/05 13/05/05 18/04/05 10/06/05 18/04/05 13/05/05 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 A number of armchairs in the lounge are worn and need replacing. Malmesbury House Version 1.10 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey, GU7 2QN 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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