Inspection on 02/11/05 for Malmesbury House

This inspection was carried out on 2nd November 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 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 18/04/05

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 Malmesbury House 18 Beauchamp Road East Molesey Surrey KT8 0PA Lead Inspector Vera Bulbeck Announced Inspection 2nd November 2005 10:00 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 Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Malmesbury House Address Malmesbury House 18 Beauchamp Road East Molesey Surrey KT8 0PA 020 8783 0444 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) Mrs Mary Gajraj Dr H Gajraj, Dr N Gajraj Mrs Mary Gajraj Care Home 19 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (2), Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the fourteen (14) service users in category DE(E) (Dementia - over 65 years of age), one (1) named person may also fall within category SI(E) (Sensory Impairment - over 65 years of age). 18th April 2005 Date of last inspection 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 DS0000013709.V254330.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken by the Commission for Social Care Inspection year April 2005 to March 2006. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. Mrs M Gajraj the registered manager for the home was present. The inspection was undertaken over 6 hours and 15 minutes. There are currently seventeen residents living in the home and the majority have lived in the home for some considerable time. A number of residents were spoken to and comments were mainly “ staff are very good, kind and helpful. However, several stated that staff do not communicate with them. Staff spoken to was relaxed, friendly and spoke highly of the management in the home. One member of staff commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. The inspector received twelve comments cards from residents and all were very positive regarding the care received However, one resident stated that staff don’t knock when entering his bedroom and another comment was “would like to go out more”. Fourteen comment cards were from relatives/visitors. And again the comments were complimentary towards the home and staff. Eight comment cards were received from Health and Social Care Professionals, which were all very positive and spoke highly of the care provided in the home. Three comment cards were also received from the G.P’s who visits the home when necessary. The comments were of satisfaction by the doctors. The inspector would like to thank the manager and staff member for their time, assistance and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report What the service does well: Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 6 The manager and staff team are committed to providing a safe and homely environment for residents. Resident’s views are continually sought to improve the service the home provides. This is maintained by the use of monthly meetings. The registered manager informed the inspector that questionnaires have been implemented and sent out to families for feedback on the services provided in the home. The home sends these out on a yearly basis. 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. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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 the following standard(s): 3, 4 and 6. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the residents identified needs. The home is able to demonstrate their capacity to meet the assessed needs of the residents accommodated at the home. The home does not offer intermediate care. EVIDENCE: Four residents files were examined during the course of the inspection. These files contained detailed information on each resident including assessment regarding their health and care needs, risk assessments and details of reviews. However, some were found to be in need of updating, and the recording could be improved on the care notes. Care plans were informative and would ensure staff could support residents in the most appropriate way. Residents spoken to confirmed that their needs were being met though some had previously commented that the activities were not as stimulating as they might be. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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 the following standard(s): 7, 9 and 10. 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: Detailed care plans identify resident’s health and personal care needs and arrangements for specialist interventions are made. The home keeps records of opticians, dentist and chiropody visits for residents. Medication stocks and records were sampled and showed that the majority of residents were receiving their medication as intended by their doctors. However, one resident who self medicates and being in control of requesting a repeat prescription is stock piling. The home has taken steps to ensure this practice is monitored by the doctor and pharmacist. A risk assessment covering this activity are in place. Medication was stored securely for the protection of the residents. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 10 Residents spoken to were generally happy with their experiences at the home and they highlighted no issues regarding their privacy and dignity. The inspector noted a number of examples where staff interacted in a positive and respectful way with residents. It was noted the Registered Manager dealt very sensitively with a resident who was concerned about a relative. There was an odour problem in one resident’s bedroom and the inspector advised the home to contact the continence adviser. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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 the following standard(s): 12 and 15. The activities provided by the home are varied, well planned, and include contact with the local community both within and outside the home. The meals in this home are varied, offering both choice and variety and catering for special dietary needs. EVIDENCE: It was pleasing to note one of the ways in which resident’s at Malmesbury House can exercise choice is through the regular residents meetings. Minutes from meetings held monthly highlighted a number of issues raised by residents including positive comments about activities, the food, and suggestions for outings. The inspector suggested that an action plan be implemented. The home involves care staff during activity sessions. This would have the dual purpose providing for resident’s personal care needs during activity sessions, but would also benefit staff that would be able to spend some time with residents engaged in recreational pursuits. A day-by-day, weekly or monthly programme of activities, in a format accessible to residents, needs to be displayed in a place where residents, their relatives, visiting professionals, and the home’s staff are likely to see it. The food at Malmesbury House received some very positive comments from residents and the Registered Manager said that the recent introduction of Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 12 cooked breakfast for one resident was proving popular. The lunch period was well organised yet very relaxed. The tables had linen cloths, napkins. One resident commented that though she liked the food, they never knew what it was until it arrived. A member of staff confirmed that the menu was in the main kitchen and residents were asked daily what they would like from the menu. This is really good practice for those residents who would not be able to benefit from a printed menu. It is recommended that a weekly menu, in a format accessible to most residents, be displayed prominently. Staff will need to continue to explain the menu to each resident who would not be able to benefit from a printed version. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 16 and 18. The home has a simple, clear and accessible complaints procedure, which includes timescales for the process. All required policies and procedures are in place to ensure that residents are safeguarded from harm or abuse. EVIDENCE: A relative confirmed they know how to make a complaint and would feel happy to tell the registered manager or a member of staff if necessary of any concerns. The home has received three complaints since the last inspection. The complaints have been dealt with appropriately and records were observed, to be well documented. The majority of staff has received protection of vulnerable adults (POVA) training. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19, 23 and 26. Recent investment, ongoing redecoration and maintenance and an increased standard of housekeeping has significantly improved the appearance of this home creating a more comfortable and homely environment for those living there and visiting. EVIDENCE: The home was comfortable and homely with many nice touches including ornaments and pictures and a cosy conservatory for residents to enjoy. On the day of inspection it was noted relatives and friends use this area to speak with their family member. The dining room was nicely laid, and new chairs and carpet, residents obviously appreciated this, one resident commenting on the nice table linen. Furnishings were of good quality and homely. All residents spoken to say they liked their bedrooms, the majority of bedrooms were carpeted and well kept. The management of the home have made a number of improvements and stated they will continue to upgrade the home. There were a few areas that require attention; these include a dispenser for paper towels is required in the Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 15 bathroom, two toilets need to be deep cleaned and a lampshade was missing in a resident’s bedroom. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30. The home has a comprehensive training programme which incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. However this needs to be updated. EVIDENCE: Training has been ongoing and the majority of staff has attended a number of training courses. However, there is a need for staff to attend updates to training particularly first aid training, which is required every three years. A training programme is in operation. However, this needs to be updated. All new staff receive induction training, which covers all mandatory training. The staffing ratio observed was adequate however; the registered manager stated staffing levels are under constant review. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36, 37 and 38. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the residents. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of residents and staff. EVIDENCE: The management of the home are seeking to employ a manager who will undertake applying for registration with the Commission for Social Care Inspection (CSCI) who is experienced and capable of managing the home. The current proprietor/manager would like to be more involved with the management and ensuring the home has an effective quality audit monitoring system. The home is not involved with residents finances this is mainly managed by relatives, or a solicitor. However, the home does hold sums of money provided by relatives for extra expenses for example hairdressing and outings. On Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 18 occasions the management would fund any extras and invoice the relatives for payment. Staff are supervised on a regular basis and goals are set for training needs and identifying how the home can improve the care provided. A number of records were observed and found to be well documented these include the accident book, fire records, training, residents and staff meetings; as well as health and safety records. However, there are some areas that require attention these include, an emergency plan to be implemented for any emergencies that may occur, and all fire records to be held in one folder. Food stored in the freezer must be dated, and the inspector would recommend that management review the cooks contracted hours to ensure the home is meeting the health and safety regulations and employment law. The home has a number of glass top tables that need to be reviewed as to the safety and welfare of residents. It was noted that a television was positioned on a small side table, which was seen to be unsafe. The management of the home agreed to move the television on the day of inspection. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 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. 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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 2 X X 2 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 2 2 Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 2 Regulation 17 Requirement Care notes to be more informative and to include whereabouts of residents when leaving the home. To review medication on a resident whom is self medicating. The daily menu record must be maintained in a file. A lampshade was missing in bedroom 11. Two toilets need deep cleaning. An emergency plan to be implemented and fire records to be held in one folder. The T.V in bedroom 12 needs to be made secure. The food kept in the freezer must be labelled and dated. Timescale for action 01/12/05 2 3 4 5 6 7 8 9 15 24 26 38 38 38 13 17 23 23 13 23 16 04/11/05 03/11/05 01/12/05 01/12/05 01/12/05 01/12/05 03/11/05 Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 21 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 6 Refer to Standard 7 19 27 30 37 38 Good Practice Recommendations To contact the continence nurse for advice. A dispenser required in the bathroom for paper towels. To review the cooks contractual hours. The staff-training programme to be up-dated. To introduce an action plan following meetings. All glass top tables to be reviewed. Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Malmesbury House DS0000013709.V254330.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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