Inspection on 20/10/05 for Maranatha Rest Home

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Maranatha Rest Home 03/07/08

Maranatha Rest Home 17/01/08

Maranatha Rest Home 16/08/07

Maranatha Rest Home 27/02/07

Maranatha Rest Home 16/11/04

Maranatha Rest Home 13/07/04

Maranatha Rest Home 11/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Maranatha Rest Home 211 York Road Southend On Sea Essex SS1 2RU Lead Inspector Mrs Michelle Love Unannounced Inspection 20th October 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maranatha Rest Home DS0000038290.V250957.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. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maranatha Rest Home Address 211 York Road Southend On Sea Essex SS1 2RU 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) 01702 467675 01702 600884 AMA Generic Ltd Mrs Rosemary Gay Bodley Care Home 15 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (15) of places Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Training in the care of older people with dementia to be arranged for care staff three months from date of registration. Radiators within the establishment to be made safe, by ensuring both covers and thermostats are fitted where required. 16th May 2005 Date of last inspection Brief Description of the Service: Maranatha Rest Home is a large established private home providing personal care and accommodation for up to 15 older people. In addition the home is registered to take up to 5 people who have a formal diagnosis of dementia. It is a detached property comprising of eleven single and two double bedrooms. There is a choice of two communal lounge areas, a dining area and a conservatory. Bedrooms are provided on the ground and first floor, with the first floor being accessed via the passenger lift. There is a small garden for the use of residents and street parking for visitors. The home is situated close to Southend town centre and to the seafront. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by Michelle Love and Pauline Marshall, inspectors over a 7.5 hour period. As part of the inspection process, inspectors spoke with several relatives, residents and four members of care staff during the day. In addition a number of records and documents were looked at and there was a tour of the premises at different times of the day. At the previous inspection to the home, seven statutory requirements and one recommendation were highlighted. Three statutory requirements have been addressed and the remaining four requirements have been highlighted again within this report. What the service does well: What has improved since the last inspection? What they could do better: The registered provider and the registered manager need to do a lot of things in order to improve the home’s documentation relating to care plans, risk assessments and healthcare records. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 6 Additional attention must be made to ensure that staffing levels within the home are appropriate for the needs of existing residents and that suitable and safe recruitment procedures are adopted when appointing new members of staff. A steady programme of staff training and staff supervision needs to be implemented. 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. Maranatha Rest Home DS0000038290.V250957.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 Maranatha Rest Home DS0000038290.V250957.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): 2, 3, 4 and 5 The home has a system for assessing prospective residents into the home. The assessment process is poor and in some cases no pre admission assessment was completed. There is no assurance that individual resident’s care needs will be and can be met. It is unclear as to whether prospective residents are given information and have the opportunity to visit the home prior to admission so as to make an informed choice as to whether or not Maranatha is a care home they wish to live in. EVIDENCE: On inspection of three resident’s care files, evidence indicated that pre admission assessments had been completed for two residents and no documentation was available for one resident. Assessments completed lacked detail and clarity and did not include specific information as detailed within the National Minimum Standards for Older People (Standard 3). Additionally some elements of the document were not completed. The home does not have a tool to assess dependency levels. No information was documented to evidence that the prospective resident and/or their representative visited the home prior to admission e.g. to look around the premises, meet other residents and care Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 9 staff etc. A contract of residency was available for all residents, however not all were signed and dated. Maranatha does not offer intermediate care. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10 Limited progress has been made on improving the home’s care plans and risk assessments. These shortfalls have a potential to place residents at risk. Records relating to residents medication showed practices were safe. EVIDENCE: Individual plans of care are available for all residents but little progress has been made to ensure that all aspects of health, personal and social care needs are identified and planned for. Care plans for individual residents remain basic and lack specific detail and clarity. The care plans identified some areas of the care that was needed for each person, but provided no detail pertaining to clear guidelines for staff to show how they are to meet these needs e.g. the care plan for one resident who is an insulin dependent diabetic did not provide specific information relating to the individuals diabetes, equipment required, treatment, frequency of visits by health professionals and no risk assessment was devised. Risk assessments were not devised for all areas of identified risk. Some individuals care plans/risk assessments had not been updated to reflect resident’s changed needs. Manual Handling assessments were evident for all residents. No formal assessments were available in relation to pressure sores, nutrition and incontinence. Written records relating to one resident stated that Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 11 “a high calorie diet must be given” but on inspection of nutritional records this did not reflect the above instructions. Some entries within the nutritional records were not completed for this resident. Discussion with three members of staff suggested that care needs of residents were being addressed even though there was a lack of clear plans and guidance. Turn charts were not evident/consistent for all residents and some gaps were seen within documentation. On the day of inspection one resident was seen to be in distress and complaining of back pain. Staff spoken with stated that the resident’s GP would be contacted later that day. Records detail that the resident had been complaining of back pain for several days but until the day of inspection no healthcare professional had been contacted to investigate the residents source of pain. No information was recorded in relation to funeral/terminal care arrangements for residents. Prior to the inspection the Commission for Social Care Inspection (CSCI) was alerted by local district nurse services to an inappropriate care practice that had occurred at Maranatha. This area of concern, involved a senior member of staff `drawing` up a resident’s insulin and supervising them to inject themselves. A further dose was administered to the resident by district nurse services on the same evening. The registered manager was advised that a misadministration of insulin had occurred. Records indicate that no management agreement/protocol had been formulated between district nurse services and the care home and that the senior member of staff supervising the resident had not received any specific training relating to diabetes/administration of insulin. The home is registered as a care home and is not registered as a nursing home. The home’s storage systems for resident’s medication, was seen to be satisfactory. A list of staff names, signatures and initials of those able to administer medication to residents was available but did not include the manager’s details. No risk assessment or information within one residents care plan was recorded relating to the resident self-administering their medication. Two omissions were noted on medication administration records whereby no staff signatures were recorded to indicate that medication had been administered to and received by residents. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15 The home has an activity programme for residents. Limited information is recorded relating to residents’ personal preferences for interests and leisure pursuits. Arrangements for visitors were satisfactory. Meals are varied and offer residents choice. EVIDENCE: The home has no activities co-ordinator but all staff working within the home, are responsible for providing a meaningful and varied programme of activities to residents. One member of staff has received specific training relating to activities for people with dementia. Limited information is recorded within individual residents care plans detailing their personal preferences, likes and dislikes. There is no dedicated monetary budget for activities but the manager is able to fund art and craft materials throughout the year. Following the inspection, the Registered Provider advised the Commission that a monthly budget for activities is provided. The home’s activity schedule/file evidenced that three weeks prior to the inspection several activities were provided for residents e.g. quiz, music and skittles. The registered manager advised that external entertainers visit the home on a weekly basis (play the piano/sing). A Christmas party/external entertainer is booked for December 2005 and it is hoped that relatives will also attend. On the day of inspection several residents were seen to enjoy a game of skittles with one member of care staff. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 13 The lunchtime meal was seen to be appealing and in sufficient quantity for residents. The meal was pleasantly presented and all residents spoken with were very complimentary regarding the quality of food. Although no second choice of meal was available, the cook is fully aware of resident’s personal likes and dislikes and an alternative can be provided. Care staff were seen to assist resident’s with their meal sensitively and appropriately. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The complaints policy and procedure enables visitors and residents to make complaints and give compliments. A Protection of Vulnerable Adults policy and procedure is available and this ensures that those people living in the home are protected from abuse. EVIDENCE: Since the last inspection the home has received no complaints. Several records of compliments were readily available. Several members of staff have received training relating to adult protection and abuse. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 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 the following standard(s): 19 The environment is homely, clean, safe and in general the premises is well maintained. One health and safety issue was raised at the time of the inspection. EVIDENCE: On the day of inspection the care home was clean and odour free. Resident’s bedrooms were personalised and individualised and in general pleasantly furnished. The home is centrally situated and is close to public amenities. All communal areas were seen to be comfortable and nicely furnished. Several residents spoken with were very complimentary regarding their personal space and the home in general. One health and safety issue was highlighted at the time of the inspection pertaining to a fire exit being blocked by a mattress. This issue was rectified immediately by the registered manager at the time of the inspection. Residents have access to a small garden and there is a separate patio area. Maranatha Rest Home DS0000038290.V250957.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): 27, 28, 29 and 30 Staffing levels in general are appropriate for the numbers and needs of current residents. The procedures for the recruitment of staff are not robust and do not offer protection to people living in the care home. Staff training is provided for all staff. EVIDENCE: Rosters showed that minimum staffing levels were being met on most occasions. On inspection of four weeks staff rosters these indicated on one occasion that minimum staffing levels were not being maintained. The registered manager advised that additional cover had been provided but was not documented within the statutory record. The staff rosters evidenced some members of staff working long days/double shifts on occasions. Some staff work twelve hour shifts. The registered manager was advised that this is inappropriate and places both staff and residents at possible risk. Currently there are 2x 30 hours care staff vacancies. No agency members of staff are currently being utilised at the home. The staff roster details that one member of staff works seven days a week without an appropriate day off. The home provides day care to a number of residents. On examination of the staff rosters staff numbers have not been increased when day care is provided. It is recommended that the home should carry out an assessment of the individual’s needs to judge if the staffing numbers are sufficient when providing day care. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 17 Since the last inspection three members of staff have been newly appointed. No staff employment file was available for one member of staff. Other files inspected, indicated that the home had not undertaken all necessary recruitment checks to ensure protection of residents. Gaps noted within each file pertained to no photograph, no Criminal Record Bureau check/POVA 1st check, no proof of ID, no visa/immigration status, no copy of a job description and no record of induction for one member of staff. Staff training records evidence that since the last inspection some staff have received training relating to the administration of oxygen, dementia, fire awareness, first aid, food hygiene, health and safety and manual handling. Little evidence was available to indicate that staff, have received training pertaining to the care and specific conditions of older people. The registered manager is currently undertaking NVQ Level 4. Five members of staff are registered to undertake NVQ Level 2 and one member of staff is to undertake NVQ Level 3. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 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 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, 32, 33 and 36 The manager is qualified and experienced to run the home. Staff and residents feel supported by the manager. The home has a quality assurance and monitoring system in place. Not all staff were adequately supervised. EVIDENCE: The registered manager has worked within a `care field` setting for a number of years and has a vast amount of experience. During the inspection staff, residents and relatives were complimentary regarding the management and care provided at the care home. Evidence was available to indicate that a quality assurance questionnaire has been devised for residents. The registered manager advised that questionnaires have also been given to visiting professionals. Since the last inspection some staff have received formal staff supervision. No records were available for some members of staff. The registered manager Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 19 advised of the difficulties encountered with trying to undertake supervision for staff in line with National Minimum Standards recommendations. The inspector agreed with the registered manager for supervisions to be conducted quarterly as an interim measure. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 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. 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 3 1 2 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 3 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 X X Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The registered person must ensure that the needs of all residents admitted to the care home are formally assessed and that the care home is suitable for the purpose of meeting individual residents needs. The registered person must ensure that all staff at the care home undertake appropriate training to the work they perform and have the necessary skills and expertise to meet the specialist needs of residents. The registered person must ensure that comprehensive and detailed care plans are devised for all residents. (Previous timescale of 15.1.05 not met) The registered person must make suitable arrangements for the resident to receive any treatment necessary from their GP or other healthcare professional. The registered person must ensure that information pertaining to pressure sores, DS0000038290.V250957.R01.S.doc Timescale for action 01/12/05 2 OP4 18(1)(c) and (i) 01/04/05 3 OP7 15(1) 01/02/06 4 OP8 13(1)(b) 01/12/05 5 OP8 17(1)(a) 01/12/05 Maranatha Rest Home Version 5.0 Page 22 6 OP7 7 OP8 8 OP9 9 OP11 10 OP27 11 OP29 12 OP33 13 OP36 their treatment and outcome are recorded on individuals care plans. 13(4) The registered person must ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. 37(1)(e) The registered person must inform the Commission of any event in the care home which adversely affects the well-being or safety of any resident. 13(2) The registered person must ensure the safe handling, administration and recording of medication. 12(2) The registered person must ensure that resident’s wishes relating to terminal care/funeral arrangements are documented. 18(1)(a) The registered person must ensure that at all times there are enough suitably qualified and competent staff on duty to meet residents needs. This refers specifically to staff deployment and the number of hours they work each shift. 17(2), 19, The registered person must ensure that robust and safe recruitment procedures are adopted at all times and records as required by regulation are available at all times. (Previous timescale of 15.1.05 not met) 26(3)(4) The registered person must and (a)(b) ensure that regulation 26 reports contain more detailed information. (Previous timescale of 15.1.05 not met) 18(2) The registered person must ensure that all staff are regularly supervised. (Previous timescale of 15.1.05 not met) DS0000038290.V250957.R01.S.doc 01/02/06 01/12/05 01/12/05 01/02/06 01/12/05 01/01/06 01/01/06 01/01/06 Maranatha Rest Home Version 5.0 Page 23 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 Refer to Standard OP2 OP5 OP8 OP28 OP31 Good Practice Recommendations All contracts for residents should be signed and dated. Evidence should be recorded depicting that prospective residents and/or a representative have visited the care home prior to admission. Where healthcare records (turn charts/nutritional records) are formally used, these should be completed on a daily basis with no gaps. 50 of care staff should achieve NVQ Level 2 The registered manager should achieve NVQ Level 4 in Management and Care. Maranatha Rest Home DS0000038290.V250957.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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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