Inspection on 06/09/05 for Marian House

This inspection was carried out on 6th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marian House 18/11/08

Marian House 06/07/06

Marian House 21/02/06

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 Clare Henderson Roe Unannounced 6 September 2005 10:10 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. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Marian House Address 100 Kingston Lane 3PW Uxbridge Middlesex UB9 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) 01895 253299 Trustees of Sisters of this Sacred Heart of Jesus and Mary Mrs Mamin Sawh CRH Care Home 26 Old age - 26 Category(ies) of OP registration, with number of places Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Minimum Staffing Notice. Date of last inspection 20th December 2004 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 G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 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 8 hours were spent on the inspection process. The Inspector carried out a brief tour of the home for the purpose of speaking with the Sisters and staff, and inspected some administration, staffing and management records, plus 3 service user plans. A total of 6 Sisters and 6 staff were spoken with as part of the inspection process. What the service does well: What has improved since the last inspection? 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 G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 6 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 Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 7 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. The home does not provide intermediate care. Sisters are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: The home accommodates religious Sisters from the Order of the Sisters of this Sacred Heart of Jesus and Mary. A copy of the Social Services care assessment is obtained and is the primary assessment for those Sisters who live some distance away and for whom an assessment by the home would be difficult to carry out. One Social Services assessment was not seen at the time of inspection but the Registered Manager has since confirmed she has this on file, and a copy has been forwarded to the CSCI. It is recommended that all assessments be kept in the Sisters individual file for ease of access. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 8 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) 7, 8, 9 and 10 The service user plans provide a clear picture of the needs of the Sisters and how these needs are to be met. Shortfalls in the management of medications potentially place Sisters at risk. Staff are courteous to the Sisters and personal support is provided in such a way as to promote and protect the privacy, dignity and independence of the Sisters. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the identified health and personal care needs of the Sisters were to be met. The service user plans were up to date and had been reviewed monthly and whenever there was a change in the Sisters’ needs. There was evidence that the Sister or her representative had been involved with the formulation and review of the service user plans. Risk assessments for falls had been completed and one accident was tracked and there was evidence of updating of the risk assessment, plus the accident had been recorded on an accident report form and in the daily records. The assessments for pressure sore risk were in place and up to date. There were no Sisters with pressure sores at the time of inspection. For one Sister with a wound the documentation was clear and up to date. Pressure relieving equipment was seen in use in the home and it was recommended that the specific equipment in use on for each Sister be recorded in the service user Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 9 plan. Assessments for nutrition, moving & handling and continence management were in place, with appropriate care plans formulated to meet any identified needs. In one instance where it was indicated that bedrails were in use, a risk assessment and consent were not available. These were seen in place in a second service user plan viewed. The Sisters are registered with one GP, who carries out a weekly surgery and also visits at other times if necessary. There is evidence of input from other healthcare professionals to include chiropodist, physiotherapist, dentist, optician and audiologist. The Registered Manager said that where necessary, mental health input is accessed from the Nursing and Residential Home Support Team. In addition, where mental health needs are identified, the GP can make referrals for psychiatric assessment and input. Samples of the medication records were viewed. Medication receipts and administration had been recorded. One medication to be given on alternate days had been removed from the blister pack on three consecutive days, with two doses signed for, and this needed to be followed up and clarified. In one instance where two strengths of a particular medication were required to make up the prescribed dose, the two tablets for administration had not been individually identified on the medication administration record (MAR) chart. The date of opening had not been written on liquid medications. Bulk prescriptions are now being obtained for some medications prescribed for several of the Sisters. All medications are stored securely and there are good practices in place for the management of controlled drugs. Daily minimum, maximum and actual drugs fridge temperatures were within acceptable range. Sticky labels had been used on the MAR chart in some instances and this practice should stop. It was acknowledged that the instructions had been hand-written on the chart prior to the labels being applied. There was a large stock of medications awaiting disposal. The Registered Manager had made appropriate disposal arrangements for medications but the system had not yet been implemented. Updated copies of the policies and procedures for the management of medications were not available in all the policy & procedure files. An additional procedure for the disposal of medications was to be formulated. The medication stock needs to be audited and all unwanted medication sent for disposal, following the required procedures. The shortfalls were discussed with the senior registered nurse at the time of inspection. A robust, ongoing system of auditing the management of medications needs to be put in place. Staff were seen to care for the Sisters in a gentle, courteous and respectful manner, and there was a peaceful and contented atmosphere in the home. There is a payphone available for the Sisters’ use. The Sisters have their own clothes and the staff respect their individual wishes. The Sisters’ preferred term of address is recorded and respected. Staff receive instruction in the specialist care needs of the Sisters and this was evidenced in the attitude of staff towards the Sisters. The Sisters privacy and dignity is respected at all times. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 10 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 and 15 The daily routines of the Sisters are respected, thus facilitating them to follow their vocations freely. Visiting is encouraged and this keeps the Sisters in touch with their families and friends. The food provision in this home is good offering both choice and variety and catering for special dietary needs. EVIDENCE: The Sisters have a daily routine based around their religious life, and staff assistance facilitates the Sisters to participate in all aspects they so wish. In addition, the Sisters spoken with said that there are regular entertainments arranged, plus theatre and shopping trips are available. The activities provided are suited to meet the needs of the Sisters and information regarding entertainments and activities is on display in the home. The home has an open visiting policy and the Sisters can choose to receive their visitors in private or in one of the communal rooms. Any concerns regarding visiting would be discussed, recorded and respected. Relatives and visitors are encouraged to maintain contact with the Sisters. The kitchen was clean and tidy. There is a menu with choices and each day the Sisters lunch and supper choices are recorded in the diary, which evidenced the provision of choice. The lunchtime meal was viewed and the food was attractively presented, and where able the Sisters serve themselves from serving dishes, rather than the food being dished up for them, thus respecting Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 11 their individuality and ability. Special diets for medical reasons are provided as necessary. The mealtime viewed was unhurried and staff were available to assist discreetly where needed. The kitchen records were up to date. It was recommended that the fridge and freezer records be reviewed to clearly identify and marry up the fridge/freezer with the record kept. The Registered Manager confirmed that this had been done following the inspection. The lunchtime meal partaken by the Inspector was well presented and tasty. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 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 standard(s) 16, 17 and 18 The home has a clear complaints procedure and concerns are promptly addressed. The Sisters’ rights are protected and advocates are in evidence. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has a clear complaints procedure, which states that complaints will be addressed within 28 days, plus it contains contact details for the CSCI. There had been no complaints since the last inspection. The Sisters spoken with said that any issues are addressed promptly. There is an advocacy service provided within the Community, with 4 Sisters being available to advocate on behalf of the Sisters, who also attend the weekly Community meeting. All the Sisters are registered on the Electoral Role. The Registered Manager said that postal votes can be arranged, plus some sisters choose to visit the local Polling Station to vote. The home has a copy of the updated Hillingdon Policies and Procedures for Safeguarding Adults (formerly POVA) in place. Staff undergo adult protection training. The homes policies and procedures are due for updating, to include their POVA documentation, and a requirement is set under Standard 33. Procedures are in place for the management of aggression, restraint, and finances. Staff spoken with said that they would report any concerns. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 The standard of décor, maintenance and cleanliness was of good quality, thus providing a pleasant and homely environment for the Sisters. Infection control procedures are followed thus minimising any risk to the Sisters and staff. EVIDENCE: The home has a replacement/refurbishment budget for 2005/06 with clear costs budgeted for maintenance to be carried out. A new fire alarm system had recently been fitted. The home and gardens are well maintained and there is a homely atmosphere throughout. The bedrooms are spacious and personalised. The requirements of the Environmental Health Inspector and the Fire Safety Officer from the most recent reports had been addressed. The home has CCTV in use externally for security purposes only. The laundry room was clean and tidy. There are two tumble dryers and three washing machines, one of which is industrial with sluice wash programmes. The home has infection control policies and procedures in place, and appropriate action is taken to address any issues identified. Risk assessments for equipment and COSHH products in use were available. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 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 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, 28, 29 & 30 The home was appropriately staffed to meet the needs of the Sisters, and staff had received training to provide them with the knowledge and skills to meet Sisters’ individual care needs. Additional supervision needs have arisen and could compromise the registered nurses time, and this in turn could have an effect on the care provision. Staff have received training to enable them to provide a good standard of care. Staff recruitment procedures are generally robust, thus safeguarding the Sisters. EVIDENCE: The home was appropriately staffed to meet the needs of the Sisters. There was no evidence to suggest that anyone felt the home was ever understaffed. The home has recently taken on four supervised placements of nurses from overseas who are studying to attain their nursing registration in this country. Part of this process involves supervision from and shadowing of the registered nurses in order to gain appropriate skills and experience. The roster shows that on some day shifts there is only one registered nurse on duty. Whilst this is usually appropriate for ensuring the every day nursing care duties are carried out, it does not allow adequate time for supervision purposes. This has been discussed with the Registered Manager and a review of qualified staffing levels must be carried out to ensure that the standard of nursing care provision is maintained, whilst ensuring the supervised placement students receive the required level of input and supervision from registered nurses. The home has an induction training programme based on the Skills for Care (previously TOPSS) core standards. On completion of the induction training staff go on to the NVQ level 2 or 3 in care training. 18 care staff are trained to Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 15 NVQ level 2 in care and 3 care staff to level 3 in care. Those who have not undertaken NVQ training attend periodic training in topics relevant to the Sisters care needs. There is evidence of ongoing training for all staff. The staff employment files viewed contained details of the applicants completed application forms, evidence of Criminal Record Bureau checks, 2 references, photographs plus terms & conditions of contract. Two of the three viewed had completed a health check questionnaire, and the need to ensure that all staff have completed this document was discussed. An issue regarding a gap in employment detail was clarified at the time of inspection. The original document verifying the nursing qualifications of the registered nurses is requested prior to employment and is also provided each time a nurse reregisters with the Nursing & Midwifery Council. The need to carry out a check against the Nursing & Midwifery Council register for all nurses was discussed, and the home took immediate action to commence the process for accessing the Nursing & Midwifery Council confirmations department. There is good practice around the interviewing of prospective members of staff in place. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 16 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) 31 and aspects of 33 The Registered Manager is appropriately qualified and experienced to manage the home. The homes policies and procedures require reviewing to ensure that practice is up to date in line with current legislation and best practice guidance. EVIDENCE: The Registered Manager is a first level registered nurse and has just completed the NVQ level 4 in Management. She has managed the home for 6 years. The Registered Manager has undertaken periodic training appropriate to the care needs of the Sisters accommodated at the home. The Registered Manager is responsible for one home only and stated that her job description enables her to take responsibility for fulfilling her role. There are clear lines of management and accountability within the home. The homes policies and procedures had not been updated since 2003 and a review of these documents must be undertaken. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 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 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 2 x x x x x Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 18 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 8 Regulation 13(4) Requirement Risk assessments to identify the appropriateness of the use of bedrails for the individual, plus a written consent for the use of bedrails must be in place prior to bedrails being used. Records must clearly identify when a medication has been administered and this must correlate the number of tablets in the blister pack. Where more than one strength of tablet is required to be administered to obtain the prescribed dose, these must be individually entered on the MAR chart for each strength of tablet and each strength must be individually signed for. Dates of opening must be written on all liquid medications. Up to date policies and procedures for medications in line with current guidance and legislation must be available. Arrangements for the disposal of medications in line with current legislation must be introduced and implemented. There must be an ongoing process of audit and review for Timescale for action 01/10/05 2. 9 13(2) 06/09/05 3. 9 13(2) 06/09/05 4. 5. 9 9 13(2) 13(2) 10/09/05 01/10/05 6. 9 13(2) 01/10/05 7. 9 13(2) 01/10/05 and Page 19 Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 8. 27 18(1)(a) 9. 10. 29 33 19 17 the management of medications and action taken to address any shortfalls identified. The staffing levels for qualified and care staff must be appropriate to meet the needs of the Sisters and to ensure adequate supervision provision. Health questionnaires must be completed by all staff employed at the home. The homes policies and procedures must be kept up to date in line with legislation and current good practice guidelines. ongoing 01/10/05 and ongoing 01/10/05 01/11/05 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. 2. 3. 4. Refer to Standard 3 8 9 29 Good Practice Recommendations It is recommended that the pre-admission documentation is maintained in each Sisters individual file for ease of access. It is recommended that the specific pressure relieving equipment in use for each Sister be recorded in the service user plan. Sticky labels should not be used on the MAR charts. It is strongly recommended that for all registered nurses, confirmation of their personal identification numbers regarding their nursing qualifications be carried out with the Nursing & Midwifery Council. Marian House G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ground Floor 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 G61-G10 s10934 Una Marian House v243012 060905 Stage 4.doc Version 1.40 Page 21 - 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. 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