Inspection on 18/11/08 for Marian House

This inspection was carried out on 18th November 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marian House 06/07/06

Marian House 21/02/06

Marian House 06/09/05

Marian House 20/12/04

Marian House 16/08/04

Marian House 25/02/04

Marian House 22/10/03

Similar services:

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Marian House 100 Kingston Lane Uxbridge Middlesex UB8 3PW     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Clare Henderson-Roe     Date: 1 8 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Marian House 100 Kingston Lane Uxbridge Middlesex UB8 3PW 01895253299 Telephone number: Fax number: Email address: Provider web address: marianhousenh@aol.com Name of registered provider(s): TRUSTEES OF SISTERS OF THIS SACRED HEART OF JESUS AND MARY care home 25 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of people who can be accommodated is: 25 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 25) Dementia, over 65 years of age - Code DE(E) (maximum number of places: 5) Date of last inspection Brief description of the care home Marian House Convent provides nursing home accommodation for 26 religious Sisters. It is a purpose built home with a chapel that is accessible to all the Sisters, regardless of their level of ability. The needs of the Sisters who live there are well catered for. All the bedrooms have en suite facilities and the communal space available is very well appointed. There is a separate section where the Community Sisters live. The home has spacious grounds and is near to Hillingdon Hospital. There are local amenities Care Homes for Older People Page 4 of 26 Over 65 5 25 0 0 Brief description of the care home nearby. The home has a peaceful and happy atmosphere. The home organises a variety of entertainments following discussion with the Sisters. Television and music facilities are also available. The fees range from four hundred and thirteen pounds to seven hundred and fifty pounds, dependent on the Sisters level of care needs. At the time of inspection 16 Sisters were accommodated at the home. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection carried out as part of the regulatory process. A total of 8 hours was spent on the inspection process. We carried out a tour of the home and we viewed service user plans, medication records & management, staff records, financial records, management records, administration records and maintenance & servicing records. The Annual Quality Assurance Assessment (AQAA) document completed by the home has also been used to inform this report. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 7 of 26 Care Homes for Older People Page 8 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are fully assessed prior to admission, thus ascertaining if the home are able to meet their needs, to include dementia care needs. Evidence: The home receives referrals from several different areas of the country. The Registered Manager ensures that Social Services carry out a full assessment of needs and that a copy of the report is obtained prior to an admission, to ensure the home are able to meet the needs of the resident. A full assessment is then carried out on admission to the home. Since the last inspection the home has registered to accommodate 5 residents with dementia care needs. Staff have received training in dementia care to ensure they have the skills and knowledge to meet the residents needs. Care Homes for Older People Page 10 of 26 Evidence: The home does not provide intermediate care. It is acknowledged that the home does offer convalescence care. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service user plan documentation is comprehensive and up to date, providing a clear picture of each resident and their needs. Medications are being well managed at the home, thus protecting residents. Staff care for residents in a gentle and professional manner, thus respecting their privacy and dignity. Information is available in respect of end of life care, and this is to be expanded to ensure the wishes of the residents and their families are fully identified and met. Evidence: We viewed 2 service user plans. These were well completed and provided a good picture of each residents needs and how these are to be met. Care plans had been completed for each identified need, and where a new need was identified a new care plan had been formulated. Risk assessments for falls were in place and had been updated following any falls. Risk assessments were also in place for any other identified risks to include the use of bedrails. There was evidence of input from the residents and their next of kin. The service user plan documentation had been updated monthly and whenever there had been a significant change in a residents condition. Care Homes for Older People Page 12 of 26 Evidence: Pressure sore risk assessments were in place. Documentation regarding skin care was viewed and this provided a clear picture of the residents needs in relation to skin care. Pressure relieving equipment was available and seen in use. Assessments for moving & handling were in place, and the equipment to be used had been identified. Nutritional assessments, pain assessments and dependency assessments were also in place. Continence care needs had been identified and care plans were in place. There was evidence of input from healthcare professionals to include GP, optician, dentist, speech and language therapist and the home has access to other healthcare professionals via the GP. One healthcare professional spoken with expressed their satisfaction with the high standard of care provided at the home. We viewed the medication management and documentation. An up to date medications policy was available. Liquid medications and eye drops had been dated when opened. All receipts, administration and disposal of medications had been signed for. For residents on warfarin therapy, blood test results were kept with the medication administration record (MAR) and the dosage adjusted according to the instructions provided. Controlled drugs are being correctly recorded and securely stored. Fridge temperatures are recorded and were within safe range. Ventilation has been installed in the medication storage area in order to ensure all medications are being stored at safe temperatures. It is recommended that the temperature in this area is recorded daily. Individual lancing devices are available for blood glucose monitoring. There was a large stock of one medication that is supplied on a bulk prescription and it was agreed that no further orders would be made until the stocks were reduced. Information regarding any drug allergies is recorded. For some residents photographs were needed and the Deputy Manager said that this would be addressed. Overall medications are now being well managed at the home. Staff were seen caring for and conversing with the residents in a gentle and professional manner, respecting their privacy and dignity. All bedrooms are individual and many had been personalised. The residents were dressed to reflect their vocations and it was clear that care is taken when laundering and caring for their personal clothing. Residents spoken with said that they were being well cared for at the home. A new telephone system has been installed with points in each bedroom and residents can make and receive calls to include contacts overseas. A camera link has been installed from the Chapel to each bedroom so that the residents who are unable to attend Mass can watch and listen to the service. Religious needs are well met at the home. Care plans in relation to health deterioration and death & dying were in place. The home also has an advanced directive which is designed to identify the wishes of the Care Homes for Older People Page 13 of 26 Evidence: resident and their families in respect of end of life care. The need to expand this document to ensure that each residents preferred place of care in their final days is identified was discussed. The home does respect the residents wishes with regard to their ongoing care and this is part of the ethos of the home and the Catholic environment. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activities provision in the home is excellent and meets the specific needs of the resident, respecting their beliefs, interests and wishes. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the individual rights and opinions of the residents are represented and respected. The food provision is good, offering variety and choice, thus meeting the needs of the residents. Evidence: The home is a Roman Catholic Convent for Religious Sisters. The home has a chapel and Mass is celebrated each day, and the daily routine centres around the religious services and observances. The home has a resident Priest who can be called upon at any time should a resident request to see him. There are other activities provided to include aromatherapy, pet therapy and music & movement. Staff have also received training in hand massage and this has been very beneficial to the residents. Fund raising activities take place twice a year and the residents are encouraged to join in this. The home has a mini-bus and outings are arranged into the local town for shopping, to garden centres and for drives out into the country. The home has a small library which is maintained by the Mobile Library service, and they provide a variety of Care Homes for Older People Page 15 of 26 Evidence: books to include audio and large print. The grounds are attractive and residents are encouraged to sit out in good weather. There is now a television link from the Chapel to residents rooms and television screens are being installed. This will enable the Services taking place in the Chapel to be relayed to residents who are in their rooms. The home has an open visiting policy and visiting is encouraged. Accommodation can be provided for visitors who need to stay over at the home. Visitors are made welcome and the importance of maintaining contact with family and friends is a high priority in the home. The Community Sisters provide an advocacy service, and there are 4 Community Sisters who can be called upon to advocate on behalf of any of the residents. Staff have attended training about the Mental Capacity Act Dementia Care, to provide them with improved skills and knowledge when caring for the residents. We viewed the kitchen and this was clean and tidy. The meal provision is good, offering variety and choice. Residents spoken to expressed their satisfaction with the food provision. We observed part of the lunch and suppertime meals, and it was clear that trouble had been taken to ensure each resident was provided with the meal of their choice, and several alternatives had been provided to meet personal preferences. Staff were seen assisting residents with their meals in a caring and gentle manner, and there was a good atmosphere in the dining room. We sampled the lunchtime meal and this was well cooked and presented and was tasty. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has robust procedures in place for the management of complaints and safeguarding issues, and these are adhered to, thus protecting residents. Evidence: The home has a clear complaints procedure that is on display. There have been no complaints received. Residents can raise any issues with the Community Sisters or with the staff, who would deal promptly with any concerns. The home has safeguarding adults policies and procedures available and also incorporates the Hillingdon Safeguarding Adults documentation into their practice. Staff spoken with were very clear to report any concerns and understood Whistle Blowing procedures. Training records showed that staff receive regular training in safeguarding adults. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained and equipment provision is good, providing a clean, homely and safe environment for residents to live in. Infection control procedures are in place and are adhered to, thus protecting residents. Evidence: We carried out a tour of the home. The home was clean and fresh and there was evidence of redecoration work having taken place in some areas. The grounds are attractive and are being well maintained. Following the last inspection an environmental audit had been carried out and action had been taken to address several areas identified for work. A list of works completed has been provided following this inspection. Since the last inspection a new call bell system has been installed. As part of this there are sensory pads that alert staff when residents at risk of falls get out of bed at night, and this is to help minimise the risk of falls during the night. 2 overhead hoists have been installed in bath & shower facilities to assist with the moving & handling of residents in these areas. There are hand rails in the corridors and grab rails in the assisted toilet facilities. The home has appropriate moving & handling equipment to meet the assessed needs of the residents. Staff were seen using correct techniques for moving & handling of residents, and were doing so in a gentle and sensitive manner. Care Homes for Older People Page 18 of 26 Evidence: We viewed the laundry and this was clean and tidy. There are 3 washing machines, one of which is of industrial standard with a sluice programme for infection control. There are 2 dryers, one of which was out of order and had been identified for replacement in the very near future. Protective clothing to include gloves and aprons are available, and risk assessments for infection control are in place. The home has a system in place in respect of legionella prevention and this includes flushing all water outlets in unoccupied rooms on a weekly basis. Some gaps were noted in the records for this, and on investigation it was found that the work had been done but the records not completed for every occasion. We recommended that this be addressed without delay to ensure records are maintained up to date. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are employed in such numbers to meet the needs of the residents and the home, thus ensuring needs can be met at all times. The training provision is good, ensuring that all staff are provided with the skills and knowledge to carry out their jobs effectively. Recruitment practices are robust and are adhered to, thus protecting residents. Evidence: At the time of inspection the home was being appropriately staffed to meet the needs of the residents. Despite the drop in resident numbers, the staffing levels have been maintained. Kitchen, maintenance, administration and domestic staff are employed in such numbers as to ensure the home is well maintained in all areas. Since the last inspection all care staff are now qualified to NVQ level 2 or 3 in care, or the equivalent. The Deputy Manager has undertaken NVQ level 4 in management. The catering staff have undertaken NVQ level 2 in customer service. The training programme for 2008/09 is comprehensive, covering topics relevant to the diagnoses and needs of the residents, to include specialist needs such as dementia care and palliative care. We viewed 3 sets of staff employment files and these contained all the information Care Homes for Older People Page 20 of 26 Evidence: required under Schedule 2 of the Care Homes Regulations 2001. The home induction programme is in line with the Skills for Care common induction standards, and all new staff undertake this training. In addition the home has an orientation induction programme, that covers more basic elements such as familiarisation with the layout of the home, fire exits and other such like areas. Staff spoken with were able to say that they had attended training sessions and that their training was keeping their skills and knowledge up to date. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Manager has the qualifications and experience to manage the home and does so effectively. Good systems for quality assurance are in place, thus ensuring an ongoing process of management and practice review. Residents monies are being well managed and securely stored. Overall health & safety is being well managed, with some training to be completed to provide up to date knowledge and practice in this area. Evidence: The Registered Manager is a first level registered nurse who has attained the Registered Managers Award. She undertakes periodic training in topics relevant to her role and to the diagnoses and needs of the residents. The Registered Manager has an open approach to her job and is supportive to residents and staff alike. The home has a system in place for quality assurance and this includes regular auditing of medications, service user plans, falls and accidents. In addition audits of Care Homes for Older People Page 22 of 26 Evidence: non-care areas are also carried out to include residents monies and home finances. The Registered Manager said that audits of health & safety are also done visually, and we recommended that these be recorded. Risk assessments are in place for use of equipment and safe working practices, and also in place for employment and associated practices. Regulation 26 unannounced visits are carried out monthly and reports are available. Resident and relative surveys were carried out by the home earlier this year, and comments were very positive. The home is to collate and publish the results. Monthly staff meetings take place and the minutes are available. The home holds personal monies on behalf of residents. The records for these were clear and up to date. Individual amounts and records are kept for each resident. We audited 3 records and amounts, and one minor discrepancy was found, however the home has since confirmed that this money has been accounted for. Monies are securely stored at the home. We sampled servicing and maintenance records and those viewed were up to date. Risk assessments were in place for equipment and safe working practices. The fire risk assessment had been updated and the shortfalls identified had been signed and dated as having been addressed. The training matrix did not evidence if all staff had undertaken health & safety training to include moving & handling and fire safety training. Training and updates in health & safety topics must be undertaken in line with current legislation and guidance. Fire drills have been carried out regularly and action has been taken to address any problems identified. Further fire drills are planned. The kitchen records were up to date and food safety is well managed. The home was clean and tidy and no health & safety issues were identified on the tour. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 11 12 That the wishes of each resident and their families be fully ascertained in respect of end of life care. So that their wishes can be recorded and met. 01/02/2009 2 38 18 All staff must undertake health & safety training and updates at the required intervals. To ensure best practice that is up to date in line with current legislation and guidance. 01/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 26 That the records of the weekly flushing of water outlets in line with legionella guidance be kept up to date in order to evidence it has been carried out. Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - 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!