Inspection on 26/11/07 for Malvern House

This inspection was carried out on 26th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Malvern House 30/11/09

Malvern House 29/06/07

Malvern House 20/03/07

Malvern House 19/06/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Malvern House 271-275 Hale End Road Woodford Green Essex IG8 9NB Lead Inspector Unannounced Inspection 26th November 2007 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 Malvern House DS0000067137.V355339.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. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Malvern House Address 271-275 Hale End Road Woodford Green Essex IG8 9NB 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) 020 8531 5081 020 8531 5084 info@malvernresthome.co.uk Malvern House Retirement Homes Ltd Sultan Sadak Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34) of places Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total beds to be used flexibly between categories (34). Date of last inspection 29th June 2007 Brief Description of the Service: Malvern House is a privately owned care home offering residential accommodation and support to 34 elderly people, including those with dementia. There are 2 double bedrooms and 30 singles. All have wash hand basins and several have ensuite toilets. There are two lifts and access is suitable for those with limited mobility. There are three bathrooms, with assisted baths. There is a conservatory, patio and attractive garden planted to lawn and flowers. The home is situated on a main road in a residential area of Chingford (in the London Borough of Waltham Forest) with access to local shops and transport links. The current fees range from £460- £512 per week. Information about the service is available at the front reception area of the home, including inspection reports, to people living in the home and to other stakeholders. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the 2nd key unannounced inspection for the service since the 29th June 2007 the last inspection. This inspection was undertaken by Regulation Inspector Harbinder Ghir on the 26th November 2007 between 10.00am and 3.55pm. The registered manager was available throughout the day of the inspection. During the inspection the inspector was able to talk to residents residing at the home, staff on duty and the district nurse who was visiting the home during the day was also spoken to. As part of the inspection the inspector toured the home, read records of people who use the service and examined documents in relation to the management of the home. At the end of the inspection the inspector was able to provide feedback to the service manager. The inspector would like to thank everyone involved in the inspection process. What the service does well: What has improved since the last inspection? At the last key inspection 26 requirements were made in the following areas; updating the Statement of Purpose and Service User Guide; pre-admission assessments; care planning; risk assessments; promoting choices; medication practices; reducing health and safety risks posed to residents; staff recruitment; recording of accidents and incidents; healthcare; lack of activities; menus; staff training; environment; staff supervision and quality assurance. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 6 At this inspection 24 of these requirements had been complied with. I was pleased to see that these requirements had been met at this inspection. 2 requirements not met at the last inspection in relation to the environment and the checks of fridge and freezer temperatures have repeated as one requirement at this inspection. The service has worked very hard to meet the requirements from the last inspection and improve the services provided to its residents. 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. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 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 Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provide prospective residents with the information they need to make an informed choice about where to live. Pre-admission assessments are completed before prospective residents move into the home, ensuring that the service will meet their needs. Trial visits are offered to all prospective residents, to ensure residents have information on the services and facilities provided at the home. Each service user has an individual written contract of the statement of terms, to ensure they agreed to the services provided at the home. The service does not provide intermediate care. EVIDENCE: Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 9 The service has updated its Statement of Purpose and Service User Guide, which provide comprehensive information on the services provided at the home. The documents are specific to the individual home and the resident group they care for. They give details what the prospective individual can expect and gives a clear account of specialist services provided, quality of accommodation, qualifications and experience of staff. Since the last inspection the service has introduced a new pre-admissions assessment form, which is very comprehensive and ensures the needs of prospective residents are fully assessed before they can move into the home. Three pre-admissions assessments were closely examined which covered the physical, social, religious, and emotional needs of residents. The service has also introduced a personal information booklet, which is also completed during the process of admission. The booklet focuses on the past history of the resident, for example where they grew up, their wartime history, their routines and information on their personalised preferences. On viewing the care information of three residents. Each resident had a contract of residency, including information on explaining residents’ rights and responsibilities in the tenancy agreement. All prospective residents and their relatives and family are given the opportunity to visit the home prior to being admitted. One resident spoken to at the inspection informed “I came to see the home before I came here, I am very happy here. We have good food, warmth, and I have a very comfortable bed. My room is very comfortable. I haven’t got a bad word to say about the place.” Another resident spoken to also informed “I came to have a look around, before deciding to move in.” Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service receive good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are set out in individual care plans. Care plans are detailed and ensure the needs of residents can be met effectively. There are clear medication policies and procedures to follow, ensuring the safety of residents. Residents’ wishes at the times of their death were not always identified, to ensure that at the time of their death, staff will treat them and their family with care, sensitivity and respect. EVIDENCE: The service has introduced a new care planning system, meeting the requirements made at the last inspection. The care planning system is now very detailed and identifies the needs of residents and how they are to be met. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 11 Information clearly sets out residents’ health, personal and social care needs. Evidence was seen of care plans being devised with the assistance of family and relatives and residents themselves, ensuring that they were person centred. For one resident, their family had provided a list of all relatives and friends that would visit their mother, to inform staff and ensure their mother’s protection. Further information included whether residents required the assistance of one or two carers. One resident’s care plan stated, “S needs assistance of one carer when bathing or showering. S chooses her daily clothes and loves wearing nail polish.” S was seen wearing nail polish during the inspection, and informed that she applies it herself. Care plans were also devised to ensure residents’ independence was promoted and concentrated on the tasks they could do independently. Another resident’s care plan stated “J is able to wash and dress himself with minimal assistance.” Each care plan identified residents’ daily routines and stated what times they preferred to go to bed and get up in the morning. Daily care recording notes evidenced residents going to bed and getting up what time they liked. One resident’s notes recorded that she likes to have breakfast in her room every morning, which she did and sometimes liked to have her meals there too, promoting her rights to choice. One resident informed “I had heard some real horror stories of care homes before, but I go to bed late, there is nothing of that sort here.” The service has also introduced a key worker system, which has allowed staff to work on a one to one basis with residents and contribute to the care plan for the individual. This has further personalised the care provided at the home. Care provided for residents with a diagnosis of dementia identified their mental and cognitive state. Staff were observed to be interacting positively with residents, talking to them and maintaining eye contact, talking slowly and in a manner which was appropriate to their communication needs. However, it is recommended that care plans for residents who have dementia, identify in more detail what their level of communication is and how their communication needs are to be met. This is Recommendation 1. On observing staff members, not all staff members were wearing name badges, making it difficult for someone with dementia to identify members of staff. It is Recommendation 2 that staff all wear their names badges, making it easier for residents to identify them. Recently the service has admitted residents who’s cultural heritage is Jewish. On examining care plans, the service identified the religious and cultural needs of residents. For one resident who was Jewish, the care plan stated “X is Jewish and likes to hold his traditions and customs” but had not specified how the resident preferred to do this. A detailed account must be provided on care plans in how residents would like their cultural and religious needs met and how the service will meet these needs. This will be stated as Requirement 2. The documentation/ health records relating to pressure care areas; management of diabetes, falls were examined. The records for these were Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 12 found to be detailed and were adequately maintained. There was evidence that care plans were being reviewed at least monthly. Monthly weight checks were undertaken for all residents and appropriate action being taken where necessary. Records indicated other health professionals such as the district nurses, optical, dental and chiropody services saw residents. The district nurse visiting the home was spoken to as part of the inspection. She spoke very highly of the home and stated, “The home liaises with us very well and lets us know if they need us. They do follow instructions, and staff are very helpful, there is a quiet and pleasant atmosphere at the home. We haven’t had anyone develop nasty pressure sores whilst at the home; they are good at preventing them. They do have people here with a high level of care needs and they are doing really well to meet their needs. They have definitely improved. Risk assessments are routinely undertaken for all residents around nutrition, manual handling, continence, falls and pressure care areas and are reviewed on a regular basis. One resident who had chosen to smoke at the home had a risk assessment completed to promote his choice and was supported by staff to smoke in the garden. He was seen throughout the day of the inspection going to the garden with the support of staff to have a cigarette. The accident and incident book was reviewed. Since the last inspection the service now ensures all accidents incidents are recorded in full and a new form to record the information has been implemented. Residents received follow up checks to ensure there were no further health-associated risks. The Commission for Social Care Inspection, in line with Regulation 37, and the Care Homes Regulations 2001, has been informed of accidents since the last inspection. The home has a medication policy which is accessible to staff. Medication records were up to date for each resident and medicines received, administered and disposed of are recorded. An audit of two residents’ medication was carried out, which was all found to be in order. Each resident now has their own medication file, with their photo and a list of their current medication. On viewing care plans, not all care plans viewed contained information on the end of life wishes of residents. To ensure a residents’ death is handled with dignity and propriety, and their spiritual needs, rites identified, their wishes must be recorded on their care plan. This will be stated as Requirement 1. Malvern House DS0000067137.V355339.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): 12, 13, 14, 15 People using the service receive good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a varied programme of activities available and residents are given the opportunity to take part in a variety of activities, which meet their recreational needs. There is a wide choice of meals in the home, to ensure they meet the needs and choices of all residents. Visiting times are flexible and people are made to feel welcome in the home, so that residents are able to maintain contact with their family and friends as they wish. EVIDENCE: Since the last inspection, the manager and the staff team have worked very hard to ensure they can meet the social needs of residents. The service employs activities an coordinator to ensure activities meet the needs of people living at the home. The home has introduced a coffee morning, which is held every Friday, inviting family and friends to attend, where they reminisce about Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 14 the past with residents. Evidence was seen of wartime memorabilia, which staff were using to encourage residents to talk about their experiences of the war. A national rationing book was seen and other pictures and photos of the war used during the sessions. Photos were seen of residents recently celebrating Halloween, the London School of Ballet putting a show on for residents, singing entertainment, the homes annual barbeque which they held in the summer, residents visiting the pub for lunch, Southend beach and taking residents on rides out in the homes transport during the day. The activities for the day were also displayed in large font in the dining room. During the inspection residents were seen participating in a keep fit class, which is held once a week. There was also an indoor activities programme at the home which included activities such as puzzles, bingo which a resident’s son has volunteered to organise, manicures, board games, sing a longs, and a church service every Sunday. The service has also introduced a monthly newsletter, which is given to all residents and their families and representatives at the home. Informing them of activities and information on events taking place at the home and developments taking place within the service. A copy of the newsletter was seen which included photographs of residents participating in activities and key information for residents on the runnings of the home. There is also a variety of books, music CD’s accompanied by a portable record player at the home. Residents were seen to be listening to different types of music in groups during the inspection, and the record player was wheeled round to different residents. The home has organised a quiet area where they have placed a computer and are looking into ways of how they can encourage residents to use IT to develop their skills. The service is commended for improving social activities for residents, particularly for those with a diagnosis of dementia. At the last inspection concerns were highlighted at not enough dining seating provided to residents at mealtimes. The service has now provided an additional six-seated dining table, which is situated in the conservatory. However, some residents were seen eating at their chairs in the lounge, which the manager informed, was their choice. The service is in the process of updating its menu, but draft menus devised by the cook were seen. There was a variety of fresh fruits and vegetables and a choice of two meals at lunchtime and at suppertime and snacks throughout the day. The inspector joined residents at lunchtime. Lunch was steak pie or sausage with creamed potatoes, vegetables and gravy. Portion sizes were appropriate, well presented and colourful and residents were seen to be eating their chosen choice. Residents were asked what they thought of the meal and comments included “Very nice, you would enjoy it,” “The food is lovely and hot,” “The lunch is very good.” Coloured plates were also provided to residents who had difficulty in recognising their meal. On observing the dining room environment, it was identified that condiments were provided but only on some tables. Gravy was also already placed on the Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 15 meal before it was given to the resident. The menu was displayed in a large font on a board in the dining room. On speaking to the cook, she was able to demonstrate her knowledge of those residents requiring special diets, for example diabetic and pureed diets. A list was seen of residents’ choice of meals for the day, but only included a list of some residents. The cook informed that those residents with dementia or who were confused could not always tell her what they wanted and so a choice was made for them. It was suggested that picture menus are provided for these residents and a pictorial menu is also displayed with the main menu at the home, to ensure residents with dementia are able to make choices and are supported to do this. To ensure the choices and rights of residents are always promoted the service should also consider providing condiments on all tables and giving access to sauces such as gravy at the table, to allow residents to choose whether they would like the sauce and how much they prefer. The service may also want to consider finger foods for those who don’t use utensils. A recommendation in relation to these findings will be stated as Recommendation 3. Visiting times were flexible and visitors could visit at any time convenient to residents. Relatives, family and friends were seen to visit residents throughout the time of the inspection and were made to feel welcomed by the staff at the home. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 16 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): 16, 18 People using the service receive good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can be assured their views are listened to and acted on. All staff have received up to date training in safeguarding adults, which ensures the protection of residents. EVIDENCE: The complaints procedure is clear and easy to follow and was displayed in the entrance of the home. Timescales within which a complaint would be investigated were stated on the complaints procedure but did not include that the Commission for Social Care can be contacted at any time or stage of a complaint being made. The procedure was amended during the inspection. A complaints and concerns logbook is kept by the home, which was viewed. There were no recent written formal complaints logged. Residents concerns were recorded which the service investigated the concerns highlighted satisfactorily. The Commission for Social Care Inspection has not received any complaints about the service. The home also holds regular residents’ meetings and records seen demonstrated that all concerns raised by residents were listened to. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 17 All staff have attended POVA training and adult protection is comprehensively covered in the induction programme. The service has comprehensive safeguarding adult procedures and protocols in place. The service has obtained safeguarding adult protection procedures devised by The London Borough of Waltham Forest. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21, 22, 23, 24, 25, 26 People using the service receive adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable home which provides a homely and pleasant living environment enhancing residents’ comfort, but further decoration and environmental safety checks would minimise risks presented to residents. EVIDENCE: The premises were comfortable, bright and airy. Furnishings and fittings in communal areas were domestic and unobtrusive. The home provides a homely environment to meet the needs of residents. The home has 30 single rooms and two double bedrooms, one of which is currently being used as a single room; some rooms have en-suite facilities. The lounge area is open plan and split into three areas, two of which are quiet seating areas. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 19 The signage and décor throughout the home has been improved since the last inspection, with signage on all toilet and bathroom doors, and residents now have a photo card of themselves placed on their bedroom door, to assist them to identify their room. There was warm lighting throughout the home. As the ability of people living with dementia to communicate with words decreases, the use of non-verbal cues and the environment are important in enabling them to cope better with daily life and aids to orientation. During a tour of the home it was identified that the general environment of the home looks tired and worn out. Further improvements need to be made to the environment and a re-decoration programme would greatly benefit residents, in particular those with dementia. The registered manager did recognise this and is looking to implement an improvement plan to update the décor of the home. The home is registered to accommodate people with dementia. Therefore, the general environment throughout the home should to reflect good practice guidelines on dementia within care homes. This will be stated as Requirement 3. During a tour of the building one bedroom was malodourus and anther resident’s bedroom carpet was badly stained. A log of fridge, freezer and food temperatures was seen, which staff did not complete consistently as recordings were not found for some days. The temperature recording of the bath water for one resident was not recorded consistently. The service must provide a safe and comfortable environment and to reduce the risks and spread of infection to residents. This will be stated as Requirement 4. This is a repeated requirement from the last inspection. Failure to comply will result in the Commission for Social Care Inspection taking enforcement action. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29, 30 People using the service receive good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment practices are robust and ensure residents are in safe hands at all times. Staff training is provided to all care staff, to ensure they are equipped with the skills and are competent to do their jobs. There is a good skill mix of staff to meet the needs of residents. EVIDENCE: The staff files of two recently recruited members of staff were closely examined, which were all in good order. References and Criminals Records Bureau checks had been obtained for both members of staff. The service has a permanent staff team and also uses bank staff to cover shifts. The staff rota was viewed, which included the full names of all staff on duty and was an accurate reflection of staff working on the day. The staffing levels at the home consist of 5 carers on shift from 8am- 2.30pm, 4 members of staff on duty from 2.30pm-9pm and 3 waking members of staff on duty at night. Staff were observed to be interacting positively with residents creating a good atmosphere at the home. Residents spoke very positively about the Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 21 staff team. One resident stated, “The carers are very friendly here.” Another resident stated, “The carers are very good.” A further resident stated, “They are very nice here, the meals are good, we get a lot of choice. We do quite a few activities; we have a lot of sing longs and plenty of drinks. My family visit any time they want to. I am happy here.” Staff certificates kept on file evidenced staff receiving a comprehensive training programme since the last inspection. Training included training in challenging behaviour; dementia; medication practices; infection control awareness; fire and safety; care planning; safe moving and handling. Currently the service has a ratio under 50 of NVQ qualified staff. Since the last inspection the service has enrolled a number of its care staff to commence the NVQ training course. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 36, 38 People using the service good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from an experienced manager who recognises their needs and adequately manages the home. Systems for service user consultation have been implemented, to ensure residents’ views underpin all self-monitoring, reviews and developments by the home. Residents can be confident that the staff team who care for them benefit from regular supervision. The systems to manage service users’ financial interests need to be further improved to ensure recorded balances are correct with the monies kept in safekeeping. The welfare of staff and residents is promoted by the home’s policies and Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 23 procedures. EVIDENCE: A new manager has been recruited since the last inspection who has had a positive and dramatic effect on the running of the home. The registered manager is a registered nurse with experience of managing services for this client group and has completed her Registered Managers Award. Through discussion and observation it was evident that the manager has the qualities and experience necessary to manage the home. One member of staff spoken to commented very positively about the new manager at the home. She stated, “The manager is very supportive, she is very open and helped me a lot since I have started work at the home. She has sat down and gone through the care planning system with me, which has given me the encouragement to do it properly.” Staff supervision records evidenced that since the last inspection, staff are supervised at least six times a year to ensure staff are provided with the skills, training and knowledge to perform the tasks required by their employment role. Residents’ records of finances were viewed and the inspector tracked the amount of money the service held for three residents. Two amounts were correct but for the third resident the amount was not correct. The remaining recorded balance for the resident was £10.85 but the amount counted was £10.95. The manager must check the recordings of expenditure to find where the mistakes have been made and ensure residents’ finances are correctly accounted for. This is Requirement 5. The service has completed its annual quality assurance programme for 2007. Residents and relatives completed surveys, which the inspector viewed. Where there was dissatisfaction with the service, the home had written to the individual personally to inform them about what action they were taking to improve the service. The service is commended for its quality assurance system and the commitments it has made in improving its services. It is recommended that stakeholders in contact with the home are also included in the quality assurance system, to ensure their views are also sought on the running of the home. This will be stated as Recommendation 4. The home also holds monthly resident meetings ensuring residents have the opportunity to further express their views on the daily running of the home. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 24 Evidence was seen of residents chairing the meetings and actively participating in discussions. Health and Safety records were inspected. All documentation was in order and appropriately completed. Fire drills were completed regularly. Monthly regulation 26 visit reports were available to view at the home, and the Commission for Social Care Inspection has also been sent copies of these reports. Visits have been completed on a monthly basis and provide sufficient information on the day-to-day operations of the home. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 3 Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP11 Regulation 12 Requirement Timescale for action 31/03/08 2 OP7 12 (4) (b) 15 3 OP19 16, 23 4 OP26 3 23 (d) The registered persons must ensure residents’ wishes in the event of their death must be recorded on their care plan. To ensure their death is handled with dignity and propriety, and their spiritual needs and rites are identified and can be met by the home. The registered persons must 31/03/08 provide a detailed account in care plans in how residents would like their cultural and religious needs met and how the service will meet these needs. The registered persons must 30/04/08 provide a general environment throughout the home, which should to reflect good practice guidelines on dementia to ensure the specialist needs of residents are met. The registered persons must 31/01/08 ensure all parts of the home are kept clean and reduce infection control and health and safety risks posed to residents. Repeated Requirement. Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 27 5 OP35 Schedule 4 The registered persons must ensure all recordings of expenditure are correct and in line with the amount in safekeeping for residents. 30/01/08 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 OP7 Good Practice Recommendations It is recommended that care plans’ for residents who have dementia, identify in more detail what their level of communication is and how their communication needs are to be met. It is recommended that staff all wear their names badges, making it easier for residents with dementia to identify them. It is recommended that that picture menus are provided and a pictorial menu is also displayed with the main menu at the home, to ensure residents with dementia are able to make choices and are supported to do this. To ensure the choices and rights of residents are always promoted the service should also consider providing condiments on all tables and giving access to sauces such as gravy at the table, to allow residents to choose whether they would like the sauce and how much they prefer. The service may also want to consider finger foods for those who don’t use utensils. It is recommended that stakeholders in contact with the home are also included in the quality assurance system, to ensure their views are also sought on the running of the home. 2 3 OP7 OP14 4 OP33 Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 © 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 Malvern House DS0000067137.V355339.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!