CARE HOME ADULTS 18-65
Margaret Roper House 447 Liverpool Road Southport Merseyside PR8 3BW Lead Inspector
Trish Thomas Unannounced Inspection 17th March 2006 11:30 Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 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 Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 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 Adults 18-65. 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. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Margaret Roper House Address 447 Liverpool Road Southport Merseyside PR8 3BW 01704 574348 01704 570432 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) Nugent Care Mr Iswurdut Busgeeth Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 23 MD The home must at all times employ a suitably qualified and competent manager who is registered with the CSCI 27th January 2006 Date of last inspection Brief Description of the Service: Margeret Roper House is a 23 bedded purpose built home situated in the larger St Thomas Moore complex, which also incorporates a residential home. The home provides long term accommodation for people with enduring mental health needs. Care is provided on four family units on 2 floors. The home is set in its own grounds and garden areas. It is on the main Liverpool/Southport Rd with regular bus services into Southport town centre [2 - 3miles]. The home is owned by the Nugent Care Society and the Registered Manager is Mr Iswurdut [Fred] Busgeeth who is a Registered Nurse [General and Mental Health] and has long experience at this level. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an un announced inspection and the methods used were, discussion with eight residents, discussion with the manager (Mr. Busgeeth), and two members of staff, reading care files, staffing records and health & safety documents and by touring the premises. Thirteen of the key standards were assessed during this visit, and for a full assessment of key standards for the year 2005/6, this report should be read alongside that of 8th June 2005. What the service does well: What has improved since the last inspection?
There were no requirements made during the last inspection of 8th June 2005. Training and development for staff has been ongoing, with further mandatory and additional training for staff having been arranged. There are proposals to establish a medical treatment room, medical consultations presently taking place in residents’ bedrooms.
Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 6 There are planned improvements to the gardens and facilities of Margaret Roper House, as part of general changes within the complex. 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. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Pre-admission assessments are carried out for prospective residents and assessment is ongoing after admission to Margaret Roper House. EVIDENCE: Evidence for this standard was obtained through reading the care files of three residents. The manager (or a senior nurse) carries a pre-admission assessment to ensure that the home can meet the person’s needs. The care file of a recently admitted resident was referred to, and aspects covered in the process included nursing, mental health, social and physical support needs, medication and risk. Psychiatric assessments are also in place, and routine mental health reviews are arranged with relevant professionals. Following initial assessment, the care plan is drawn up, to meet identified needs. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Care plans which were read, addressed the residents’ assessed needs and were meeting the stated aims for the residents. Residents are provided with the support they need to make informed decisions and follow their chosen lifestyle. Residents’ are supported to take risks as part of their independent lifestyle. EVIDENCE: Individual care plans are drawn up with the involvement of the resident (representatives), and are signed by them. Interventions to address the needs identified in assessments, were set out in the relevant care plans. The more established care plans, which were read, had been regularly reviewed (one care plan was recently established). Residents who commented said they were satisfied with the support provided in the home. There was evidence on care plans of input from external agencies such as health, paramedical and advocacy services. Regular psychiatric reviews are carried out to assess progress and ensure that the resident’s needs are being met by the services and facilities of the home. The home has a designated G.P. who visits the home weekly in addition to individual referrals for treatment. The support needs of residents vary, some of the residents being physically frail. In speaking with one such resident it was evident that her support needs were
Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 10 being met to her satisfaction, and her religious beliefs respected by staff in the home. Reference was made to residents’ care files and a number of residents commented on the lifestyle of the home. There are systems to support residents in decision-making. Prior to admission, prospective residents are provided with home’s information booklets. When they are living in the home, consultation with them is ongoing through meetings and reviews. All residents have a key worker and access to independent advocacy services if required. Residents are supported in maintaining contact with family, friends, who are welcome to visit the home, as confirmed by those who commented. Reference was made to residents’ risk assessments and reviews. Their independence is supported through the individual risk management strategies in place. Various levels of need and dependency were observed amongst residents. Some leave the home without escort and make full use of local shops, amenities and churches. If necessary, residents are accompanied by staff, for G.P. and hospital appointments and shopping trips. Residents who commented were satisfied with the lifestyle promoted in the home, which appears to support the range of needs and opinions identified. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 17 Residents are consulted as to their preferences and are offered a range of in house and community based activities. Residents’ wellbeing is promoted through a nutritious, varied and balanced diet. EVIDENCE: There was a pleasant atmosphere in the home and after their meal, some of the residents were taking part in a St. Patrick’s Day sing-along, with support staff and the activities co-ordinator. The conservatory had been decorated in green for the occasion and everyone appeared to be having a good time. Activities are often themed for special occasions (as on this day), and there is an ongoing activities diary covering in-house and community based leisure pursuits. Residents were aware of the activity for that day and were taking part by choice. Some said they like playing bingo, another is interested in I.T. and others enjoy crafts, art and writing. Residents appear to treat the home as their own and appeared comfortable in each other’s company, and with staff. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 12 The home is divided into units, each being self-contained with dining and lounge areas. The mealtime appeared to be friendly and relaxed. Afterwards, residents were involved in clearing the tables and washing up. They said they had enjoyed Irish stew that day, and that the meals are consistently good with plenty of choice and alternatives. The menu gave evidence of a variety of meals and desserts. The main kitchen was well managed and hygienic and records were well maintained. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home has a satisfactory system for the management of residents’, prescribed medication. EVIDENCE: Medication administration records were satisfactorily maintained and medication is stored securely. The manager carries out internal audits of medication held in the home each month and instruction is provided for relevant staff. Medication reviews for individual residents are carried out regularly, as part of the home’s review system. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home has policies for Protection of Vulnerable Adults and “Whistle Blowing.” Instruction in Local Authority Adult Protection Procedures is a requirement of this inspection. To protect residents’ interests, there are systems in place for the management of residents’ personal allowances. EVIDENCE: Discussion took place with the manager, Mr. Iswurdut Busgeeth. The organisation has the relevant internal policies and procedures for staff to follow if abuse is suspected. The home did not have a copy of Sefton Council’s Adult Protection Procedures and the manager was advised to obtain a copy, and arrange for the relevant instruction for staff in its use. The manager discussed arrangements for the management of residents’ personal allowances and records were seen. There are extra charges to residents for services such as hairdressing and chiropody. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed EVIDENCE: Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Staff have the competencies and qualities required to meet residents’ needs. The home operates a thorough recruitment procedure ensuring the protection of residents. There is a staff training and development programme, which is targeted to ensure that staff fulfil the aims of the home and meet the changing needs of residents. EVIDENCE: Discussion took place with the manager and reference was made to rosters, staffing and training records. The home employs nursing staff to who are qualified to support the mental health and general nursing needs of residents. All Pin numbers for qualified staff were up to date at the time of inspection. A sample of training plans was seen, and the manager said they are in place for all staff. Care staff receive induction training on appointment and ongoing mandatory training. Further training recently arranged for staff included Challenging Behaviour, Bereavement Counselling and Continence Care. The recruitment procedure followed includes the assessing competence through interview, taking up references and obtaining Criminal Records Bureau and POVA Clearances. On taking up their post, staff are issued with job descriptions and contacts of employment. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40,42 Effective quality assurance and quality monitoring systems, based on seeking the views of residents are in place. The manager ensures, so far as is reasonably practicable, the health, safety and welfare of residents and staff are safeguarded. EVIDENCE: Residents who commented felt their views were valued. There are monthly residents’ meetings and a residents’ committee. A quality assurance assessment is carried out each year by an external organisation and questionnaires are issued to residents to obtain their opinions on the service provided in the home. The home has a health & safety policy and there are procedures in place for infection control. Records of fire safety procedures were satisfactory and record regular fire safety tests, maintenance, instruction and drills. Building risk assessments were in place, and the manager carries out daily safety audits, when he walks the building. The home employs maintenance staff and maintenance and health & safety certification was in order, other than the
Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 18 landlord’s gas certificate, which was not available. A requirement is given in the relevant section of this report. Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X X 3 X 2 X Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 (6) Requirement The manager must arrange for staff to have access to Sefton’s Adult Protection Procedures and undertake instruction in its use. The manager must obtain an up to date and satisfactory gas certificate. Timescale for action 17/06/06 2. YA42 23 (2) 17/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Margaret Roper House DS0000017250.V287065.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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