Inspection on 21/02/06 for Marian House

This inspection was carried out on 21st February 2006.

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

Marian House 18/11/08

Marian House 06/07/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marian House 100 Kingston Lane Uxbridge Middlesex UB9 3PW Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 21st February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Marian House DS0000010934.V279444.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 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. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marian House Address 100 Kingston Lane Uxbridge Middlesex UB9 3PW 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) 01895 253 299 TRUSTEES OF SISTERS OF THIS SACRED HEART OF JESUS AND MARY Mrs Mamin Sawh Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 26 BEDS FOR ELDERLY FRAIL NURSING MINIMUM STAFFING NOTICE Date of last inspection 6th September 2005 Brief Description of the Service: 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 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. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 10 hours were spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, staff & administration records, maintenance and servicing records. A pharmacy inspection was also carried out. 3 Sisters and 4 staff were spoken with as part of the inspection process. The purpose of this inspection was to follow up the requirements and recommendations from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. What the service does well: What has improved since the last inspection? Improvements in the service user plans had been maintained, with some minor shortfalls to be addressed. The majority of requirements from the last inspection had been addressed. Improvements in the management of medications had been made, with further improvements required to meet this standard. The staffing provision had been reviewed and was appropriate to meet the needs of the Sisters. Staff recruitment procedures are robust. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 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. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 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 Marian House DS0000010934.V279444.R01.S.doc Version 5.1 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): None EVIDENCE: There have been no new admissions since the last inspection. The home does not provide intermediate care. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 9 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 Overall the service user plans are well formulated, but shortfalls could lead to some of the Sisters needs not being fully identified and met. Medications are generally well managed in the home, with minor shortfalls to be addressed. Staff care for the Sisters in a gentle and courteous manner, respecting their privacy and dignity. EVIDENCE: Four service user plans were viewed as part of the inspection. Overall these were up to date and gave a clear picture of the Sisters needs. There was evidence of care plans being formulated for newly identified needs and also of the service user plan being updated promptly on the Sisters’ return to the home following a hospital admission. Risk assessments for falls had been completed. For one Sister who had experienced a fall, an accident form had been completed and the falls risk assessment updated. An entry had not been made in the daily record, and this was discussed at the time of inspection. Care plans had been signed by the Sisters or by their next of kin, with some newly formulated ones to be signed. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 10 Documentation for wound care was in place. For one Sister the risk assessment for pressure sores needed updating to reflect the current condition of their skin. Dressing changes are mainly recorded in the daily record. Pressure relieving equipment was seen in use in the home and the specific equipment in use for each Sister had been recorded in the service user plan. In one instance, monthly weights had not been carried out. It was explained that this was due to the fact that it was not possible to weigh the person. The need to clearly document this in the service user plan was discussed. Risk assessments for bedrails had been completed, although some more information to clearly identify the risk to each individual was required. This was discussed with the Registered Manager. Consents for the use of bedrails had been obtained. Moving & handling, continence and nutritional assessments had been carried out, and where needs were identified a care plan formulated. The CSCI Pharmacist Inspector carried out a full medications inspection on 21/02/06 and a separate inspection report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. The abbreviation ‘MAR’ stands for Medication Administration Record. Staff were seen to care for and speak with the Sisters in a gentle, courteous and respectful manner, and there was a peaceful and contented atmosphere in the home. The Sisters have their own clothes and their individual wishes are respected and they are cared for with dignity and privacy. The Sisters’ chosen term of address is recorded and respected. Staff receive training in meeting the specialist care needs of the Sisters. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 11 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): 14 Advocacy care is available and the Sisters are encouraged to exercise their independence wherever they are able, to help maintain their quality of life. EVIDENCE: There is an advocacy service provided within the Community, with 4 Sisters being available to advocate on behalf of the Sisters, and these Sisters also attend the weekly Community meeting. The Sisters are encouraged to maintain their independence in areas that they are able to do so. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 12 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): 18 Procedures for Adult Protection need to be updated to ensure that the Sisters are robustly safeguarded. EVIDENCE: There have been no complaints since the last inspection. The home follows the Hillingdon Safeguarding Adults procedures. The homes own policies and procedures for Adult Protection are still to be updated. One POVA issue was identified on the day of inspection and appropriate action has been taken to report this finding. The importance of ensuring all staff are clear on all aspects of Safeguarding Adults protocols was discussed with the Registered Manager at length at the time of inspection. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 13 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 There is ongoing refurbishment and redecoration, thus providing a good standard and homely atmosphere for the Sisters. EVIDENCE: There was evidence of refurbishment on the first floor, with replacement flooring in the bedrooms and landing areas. The décor throughout the home was in good condition, and the furnishings and fittings are appropriate to meet the needs of the Sisters. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 14 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 and 29 The home is appropriately staffed to meet the needs of the Sisters. The systems for the recruitment of staff are robust and safeguard the Sisters. EVIDENCE: Since the last inspection the Registered Manager has reviewed the staffing to include the number of supervised placement students, and has adjusted the numbers undergoing their training. At the time of inspection the home was appropriately staffed to meet the needs of the service users. The Inspector viewed two sets of staff employment records for recently employed staff. These contained all the required information. The new staff application form did not request a reason for leaving previous places of employment, and this was updated at the time of inspection. Copies of recent photographs were available, and the Registered Manager explained that the home was obtaining original photographs for all staff where needed. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 15 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): 33, 35, 36 and 38 Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Shortfalls in the systems for the management of Sisters monies needed to be addressed to ensure robust procedures are in place. Staff receive supervision, thus promoting communication and review of practice. Some systems for health & safety in the home need reviewing to ensure that maintenance and servicing systems are robust and safeguard all people in the home. EVIDENCE: The home has a Quality Assurance Manual in place, which is comprehensive and covers all the National Minimum Standards for Older People. In-house audits for areas such as food, medications and service user plans are carried out monthly. A six monthly health & safety audit is carried out. Satisfaction surveys for the Sisters are due to be carried out, plus surveys for visitors are freely available. Regulation 26 inspection reports are received by the CSCI. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 16 There are still policies and procedures that require updating, and this is a repeat finding from the last inspection. Although it is acknowledged that work had been done to update some of the documentation, periodic reviews and where necessary updates of all the homes policies and procedures must be carried out. Personal allowances are held for 18 Sisters, and Social Services or Primary Care Trust funding has been sorted out in recent months. A record of income and expenditure is maintained, and receipts for expenditure are also kept. In three instances a substantial amount of money was being held. On checking the balance for one of these amounts, a shortfall was identified. The need to carry out an audit of all monies held and to investigate any discrepancies identified was discussed at the time of inspection, and confirmation that this has been done has since been received by the CSCI. Safe facilities are in use, plus there is a lockable facility in each of the bedrooms. Annual audited accounts are available, and the accounts for the home are incorporated with the accounts for the whole Religious Order, and any losses are met from the central fund. The Registered Manager has a programme of formal supervision for all staff providing care. There was documentary evidence that supervision takes place seen in the staff files. The need to ensure that each member of staff providing care has a minimum of 6 formal supervision sessions per year was discussed. The records of staff mandatory training were not viewed at the time of inspection, and the Registered Manager has since confirmed that staff have undergone mandatory training at the required intervals. Updates of Food Safety training are in the process of being arranged. At the time of inspection the maintenance person had been on leave for some weeks. It was not easy to ascertain from the records when equipment and systems had last been serviced. A list of all servicing and maintenance dates has since been forwarded to the CSCI. Some of the weekly checks, for example, fire alarm checks and hot water outlet checks, had not been kept up to date. A new Fire Log book was in use, and the previous book was not available for inspection. Risk assessments for safe working practices had been recently updated, but dates of completion for March 2006 and June 2006 were seen. The importance of ensuring that all documentation is dated at the time of completion, and no pre or post dating takes place, was discussed. Risk assessments for kitchen equipment were clear and correctly dated. Some of the records for the flushing of shower infrequently used were unclear. A copy of the updated Health & Safety policy and procedures could not be found, and was therefore not freely available to the staff. The importance of keeping records clear, accurate, up to date and available for inspection was discussed with the Registered Manager. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 17 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 3 X 1 Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP8 Regulation 13(4) 13(4)(7) Requirement Following a fall, all documentation to include the daily record must be completed. Bedrail assessments must clearly identify the safety and appropriateness of the use of bedrails in each individual instance. Service user plans must accurately reflect the current condition and needs of each service user, to include a record of any aspects of care that cannot be completed and the valid reason for this. The homely remedies procedure and list must be updated and signed and agreed by the GP. The fridge temperature must be recorded daily. All medicines must be administered as prescribed. All medicines must be accurately recorded when administered. If not administered then the correct endorsements must be used. The history of allergy must be stated either on the MAR or the DS0000010934.V279444.R01.S.doc Timescale for action 10/03/06 31/03/06 3. OP8 7(1)(a) 17/03/06 4. OP9 13(2) 01/04/06 5. 6. 7. OP9 OP9 OP9 13(2) 13(2) 13(2) 22/02/06 22/02/06 22/02/06 8. OP9 13(2) 01/03/06 Page 19 Marian House Version 5.1 9. OP9 13(2) 10. OP18 13(6) 11. OP33 17 12. OP35 13(7) 17(2) 13. OP38 17 13(3) 13(4) 14. OP38 15. OP38 13(4) 16. OP38 23(4) cover sheet. If there is no allergy then no allergy known must be stated. The labelling of medicines must correlate with the MAR and the doctors prescription. All medicines must be thoroughly checked when received into the home. All staff must be clear of the procedures to be followed in the event of any adult protection concerns. The homes policies and procedures must be kept up to date in line with legislation and current good practice guidelines. (previous timescale of 01/11/05 not met) Copies must be freely available, and staff must read the updated documentation. In relation to the Sisters personal monies, clear and accurate records of income and expenditure must be maintained. The records must be audited on an ongoing basis. Records for maintenance and servicing must be accurate, up to date and be readily available for inspection. The risk assessments for safe working practices must reflect the time of completion accurately. The health & safety documentation must be up to date and available to staff at all times. Fire safety records must be available for inspection. 01/03/06 01/03/06 01/05/06 10/03/06 01/04/06 17/03/06 01/04/06 10/03/06 Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 20 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 OP9 Good Practice Recommendations That the pharmacist updates the MAR removing all discontinued items. The home must work with the pharmacist to identify those items requiring deletion. Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Marian House DS0000010934.V279444.R01.S.doc Version 5.1 Page 22 - 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. 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