Inspection on 15/08/05 for Marden Court

This inspection was carried out on 15th August 2005.

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

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

Other inspections for this house

Marden Court 19/03/09

Marden Court 12/03/07

Marden Court 27/01/06

Marden Court 01/02/05

Marden Court 25/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Marden Court Quarr Barton Calne Wiltshire SN11 0EE Lead Inspector Thomas Webber Unannounced 15 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Marden Court Address Quarr Barton Calne Wiltshire SN11 0EE 01249 813494 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Orders of St John Care Trust Ms Jane Ridgwell Care Home 28 Category(ies) of MD(E) Mental Disorder (4) registration, with number OP Old Age (28) of places Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents who may be accommodated at any one time is 28. 2. No more than 4 residents over the age of 65 years with a mental disorder may be admitted at any one time. Date of last inspection 1st February 2005 Brief Description of the Service: Marden Court was built in the 1960’s as a purpose built residential home offering accommodation and personal care to a total of 28 residents over the age of 65 who require care primarily through old age, although the home is also registered to accommodate 4 residents who have mental health needs. Two of the 28 beds are used for respite care. The home also provides day care facilities for 16 residents. The home is set in its own delightful gardens, in a quiet residential area close to the centre and facilities of the market town of Calne. The home was originally opened in 1960’s as a local authority home and was taken over by the Order of St John’s Care Trust in 2000. The registered manager is Ms Jane Ridgwell. Residents are provided with their own bedrooms and these are located on the ground and first floor levels and are accessed by the use of a passenger lift. A call bell system is installed in each room, which can be used by residents to call for staff assistance. The home provides suitable communal space together with adequate bath and toilet facilities. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 09:40 to 13:05. The inspection primarily focused on the direct care provided to the residents rather than the underlying administration of the home including policies and procedures. A tour of the premises was undertaken and the views of seventeen of the twenty-four residents in situ were sought on an individual and group basis, regarding the care and services provided by the home. The records in relation to assessments, menus, complaints and staff recruitment were checked and the staffing levels were also discussed with the registered manager. What the service does well: What has improved since the last inspection? The home has developed various systems which relate to the re-establishment of residents’ questionnaires as part of its quality assurance system, the level of staff supervision and the increase of staff training. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 6 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. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 5 and 6 All residents are assessed, usually prior to admission, to ensure that the home can meet their needs. Opportunities are available for prospective residents and their families to visit the home, prior to admission, to assess the quality of facilities and suitability of the home. EVIDENCE: The home completes its own assessment tool, known as its long term assessment/care plan, in relation to all prospective residents admitted. In addition, the home also obtains a copy of the community care assessment or equivalent for those residents funded by social services. Documentary evidence was available to confirm that the home’s assessment tool had been completed in relation to the resident recently admitted to the home. Opportunities are available for prospective residents and their relatives or close friends to visit the home prior to admission. As part of the introductory process they are given the opportunity to meet with staff, other residents, tour the premises and ask any questions relating to the running of the home. It is not unusual in some cases for prospective residents to have spent time in the day centre and/or for respite care within the home prior to being admitted at a Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 9 later date on a permanent basis. Evidence was available to confirm that the resident recently admitted to the home had made a pre-visit with his family. The home does not accommodate residents for intermediate care therefore this Standard is not applicable. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8 and 10 The health care needs of the residents are being appropriately met and residents’ privacy and dignity are respected at all times. EVIDENCE: Residents admitted to the home are registered with one of three different surgeries and any doctors’ appointments tend to be held within the home although occasionally residents do attend the surgery. Doctors and district nurses’ appointments held within the home are undertaken in the privacy of the residents’ bedrooms and this was confirmed by residents spoken to. Records of these visits are kept in the office and those seen together with those residents spoken to confirmed that their health care needs are being met. Appropriate aids are provided for those residents with incontinent and mobility problems. Residents access other health care services such as dental, opticians and chiropody as and when required. Residents are provided with their own bedroom where they can conduct all their personal affairs in complete privacy, including medical examinations and any treatment. In discussion with residents, they confirmed that they can also choose who and where to see any visitors and their mail is given directly to them unopened. The home provides a payphone for residents’ use, which is located by the front entrance, although this facility can be moved to the Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 11 hairdressing salon for complete privacy when being used. The home also has a hand set phone, which residents can use in the privacy of their bedrooms. In addition, residents can have a telephone installed in their bedrooms and a number of them have availed themselves of this facility. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Opportunities are available for residents to pursue social, religious and recreational activities. Residents maintain contact with their families, friends and relatives in accordance with their preferences. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet and meals are taken in a congenial and relaxed setting. EVIDENCE: It was apparent from observations and discussions with residents that they can choose where and how to spend their time including when to get up and go to bed. Residents have the opportunity to pursue their own individual interests as well as being able to participate in the various organised activities arranged by the home, should they wish to do so. Organised activities are provided within the main part of the home and the day centre and residents and those receiving day care can opt to join in the various activities provided. Residents talked positively about the level of activities and outings available and at the time of the inspection, activities were in progress both within the day centre and within the home’s garden. Hairdressers visit the home two to three times a week and the mobile library visits regularly. A Sunday service is held within the home weekly with communion being provided monthly by the Church of England vicar. Individual visits can also be arranged by other religious denominations if required. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 13 A policy and procedure has been established regarding residents maintaining contact with their family, friends and representatives and visitors are welcome at any time. Residents can choose whom and where to see their visitors either in the privacy and comfort of their own bedrooms or the communal rooms available. There are a number of indicators to show that residents can exercise personal autonomy and choice as identified in discussions with them and observations made. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose where to spend their time, where to eat, and what activities to participate in. A satisfactory and varied five weekly menu is in operation, which provides a choice at breakfast and lunchtime, except when a roast is provided on a Sunday. A set meal tends to be offered at teatime. Since the last inspection, a record of refreshments available at suppertime is now maintained. Drinks and snacks are also available at other set times of the day. Residents can choose where to eat their meals, either in the dining room or their bedrooms. Residents spoken to commented very favourably about the quality and quantity of food provided. They also confirmed that the food is well presented, they receive a choice and are provided with plenty of food. Mealtimes are conducted in a relaxed and congenial atmosphere. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Information is provided to residents on how to complain should they wish to and the residents felt that any concerns would be listened to and acted upon. However, the area of weakness lies within the monitoring of the outcomes of complaints investigated. Appropriate procedures are in place to protect the residents from abuse. EVIDENCE: Each resident is provided with a copy of the home’s complaints procedure, which specifies how and who would deal with any complaint. The procedure also informs complainants that they can contact the Commission for Social Care Inspection at any stage should they wish to do so. Since the last inspection the home has received three complaints, which related to the attitude of a staff member and the lack of response to a phone call, the temperature to the lounge and the lack of speed in meeting the resident’s needs. The outcome of the complaints were not clearly recorded but in discussion with the manager the first complaint was deemed to be unresolved with the other two being upheld. Two different forms are used for the recording of complaints and are known as the suggestions and complaints record, which has a space to record the outcome, and the other is known as the verbal complaints/non serious issues record. However, this form does not specifically identify the outcome. It was questioned whether the use of both forms was necessary and consideration should be given to the discontinuation of the second form. Residents spoken to commented that they had no complaints and some stated that if they had any concerns, they felt confident that these would be suitably dealt with by the home. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 15 The home has appropriate procedures for responding to suspicion or evidence of abuse. Evidence is available to show that all staff have been provided with a copy of the shortened version of the Wiltshire and Swindon Vulnerable Adults procedures which is in line with the Department of Health Guidance “No Secrets” document. The manager confirmed that new staff receive some basic training regarding these procedures at induction and some staff have also attended a more detailed course on this subject. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24 and 26 The home is accessible, safe and suitably maintained to meet the residents’ individual and collective needs. Residents are provided with individual bedrooms which they have personalised to their individual wishes. Residents have access to a sufficient number of toilet and bathroom facilities. The home is maintained to a satisfactory standard being clean, tidy and comfortable and provides suitable laundry facilities. EVIDENCE: The home is located within close proximity to the town facilities of Calne, although the road to town is steep in places and without a pavement. The home is maintained to a satisfactory standard being clean, tidy, and comfortable and provides sufficient heating, lighting and ventilation. The home has an ongoing programme of maintenance to enhance the residents’ living environment. The decoration, furnishing and fittings are also suitably maintained, although the standard of redecoration to residents’ bedrooms varies. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 17 The home provides a range of communal areas which include a large dining room with a small sitting area, an additional small sitting area by the shop/bar, a lounge and a conservatory which is designated as the smoking area thus providing a smoking free zone to the other communal areas and to residents’ bedrooms. Residents can access the facilities in the day centre. There is also a bar/shop and a hairdressing salon within the premises and these are located on the ground floor. The home has a spacious and well maintained rear garden which is used by residents weather permitting, although some fencing is due to be replaced. The home provides sufficient bathroom and toilet facilities, which meet the needs of the residents. Residents’ bedrooms are suitably furnished and equipped to ensure comfort and privacy. Residents can and have brought items of furniture and personal possessions to make them homely and residents have personalised their bedrooms to their individual wishes. Locks have been fitted to residents’ bedroom doors and keys have been provided to residents where these have been requested. Residents’ bedrooms have also been provided with a lockable storage space. There is still a need to provide at least two accessible double electric sockets to each bedroom and the Trust intends to undertake this work as part of its existing five-year improvement and replacements work. Residents spoken to commented favourably about the standard and cleanliness of the accommodation provided, stating that their bedrooms are kept clean and tidy. The home is maintained to a satisfactory standard being clean, tidy and, in the main, free from offensive odours. The laundry facilities are located in a variety of places within the home: on the ground and first floor levels and could benefit from being situated in one room which provides sufficient space to accommodate all the required facilities. Residents’ clothing is labelled to ensure that their garments are appropriately returned. Residents spoken to commented very favourably about the laundry arrangements in place, stating that their clothing is suitably returned in good condition. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home continues to provide sufficient numbers of staff on duty at all times to meet the needs of the residents. Residents are supported and protected by the home’s recruitment practices. EVIDENCE: The deployment of staff continues to ensure that there are four care staff on duty in the mornings with three on in the afternoons and evenings. The home now provides three members of waking night staff on duty each night. There are two members of staff on duty in the day centre at any one time. The above staffing levels include the care leaders but exclude the manager and number of ancillary staff employed. The manager is in the process of shortlisting potential staff to cover the current vacancy and future vacancies. The Trust has submitted a detailed staffing proposal to the Commission, which will be considered at a meeting in September 2005. Residents spoken to commented very favourably about the care provided by the staff stating that the staff are marvellous, very good and although the staff are very busy, they are able to spend time with them. Staff were observed to undertake their duties in a caring and attentative manner The Trust has established a policy and procedure for the recruitment of new staff. A sample of staff files showed that, in the main, appropriate recruitment practices are being followed. However, the Trust could still benefit from adopting the policy of obtaining a person’s full employment history as opposed to the ten-year one currently in use. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 The home is run in the best interest of the residents with opportunities being available for them to comment on the care and services provided by the home. Staff are being appropriately supervised. EVIDENCE: Questionnaires have been re-introduced and have been completed by residents and their relatives. These have been sent to the Quality Assurance manager who will produce a report, which will identify both the positive and any negative aspects relating to the care provided by the home. The results of this survey will subsequently be made available to all the residents and their relatives, as well as a copy being sent to the Commission. Various other monitoring processes are also in place. There are a range of mechanisms in place for the manager to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include daily handover meetings, Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 20 regular staff meetings and informal and formal staff supervision. Supervisors have undertaken training in supervision. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x 2 x x 3 x x Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 22 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 16 Regulation 22 Requirement The responsible individuals must ensure that the outcomes to all complaints investigated are clearly recorded. The responsible individuals must produce a report of the recent review conducted i.e. quality assurance and make it available to the residents as well as sending a copy to the Commission for Social Care Inspection. Timescale for action 30/09/05 2. 33 24 (2) 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 29 Good Practice Recommendations The responsible individuals should strongly consider obtaining a full employment history as opposed to a ten year one currently in use. Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 23 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Marden Court D51_D01_S28292_MardenCourt_V240753_150805_Stage4.doc Version 1.40 Page 24 - 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!