Inspection on 01/06/05 for Marian House Nursing Home

This inspection was carried out on 1st June 2005.

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 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 Nursing Home 20/08/07

Marian House Nursing Home 24/10/06

Marian House Nursing Home 06/01/06

Marian House Nursing Home 18/11/04

Marian House Nursing Home 25/05/04

Marian House Nursing Home 25/02/04

Marian House Nursing Home 28/08/03

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

CARE HOMES FOR OLDER PEOPLE Marian House Nursing Home 32 Walmley Ash Road Walmley Sutton Coldfield B76 1JA Lead Inspector Jane Walton Announced 1 June 2005 st 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 Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Marian House Nursing Home Address 32 Walmlet Ash Road Walmley Sutton Coldfield B76 1JA 0121 240 8000 0121 240 8039 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) Mohammed Younis Ms Jo Stinton Care Home 35 Category(ies) of PD over 65 years of age (35), Terminally Ill (35) registration, with number of places Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 35 places - over 50 years general nursing care for physically disabled service users where disablement began before pensionable age.. Date of last inspection 18th November 2004 Brief Description of the Service: Marian House Nursing Home is a private home owned by Walmsley Care Homes Limited, and provides nursing care for up to 35 older adults. It is also able to offer care to adults over 50 years of age with a physical disability. Marian House is a purpose built home with accommodation on two floors. There are fourteen single bedrooms on the ground floor and twenty one single bedrooms on the first floor, many of which have en suite facilities. There are also ample shared bathroom facilities. There are lounge/dining areas situated on both floors. There are a range of aids and adaptations designed to accommodate residents with limited mobility , such as hoists, grab rails, a passenger lift, nurse call system and assissted bathing and toilet facilities. The home is fully accessible by residents in wheelchairs. The home is situated in a residential area and there is easy access to public transport. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced inspection was undertaken by one inspector over two days, and was assisted throughout the process by the Registered Manager and her deputy. There were 34 residents in the home with one in hospital. The inspector spoke with two visitors to the home, and eight residents. Information was also gathered by observing staff performing their duties and formal discussions with two of the staff. Ongoing discussions throughout the inspection process took place with the manager, deputy manager and the administrator. The inspector also met briefly with the owner of the home. Care records were examined and a medication audit carried out. What the service does well: What has improved since the last inspection? The manager has formalised her commitment to Marian House by successfully completing a fit persons interview undertaken by the Commission of Social Care Inspection (CSCI), and is now the Registered Manager of the home. The Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 6 residents are fully involved in decision making, where practicable, and their views sought. One resident said “We have regular residents meetings where we can put our views and opinions across to the manager and other staff, and they really seem to listen to what we have to say” 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 Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, & 5 Residents are enabled to make an informed choice about the home. All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure needs are met. EVIDENCE: The home has a comprehensive statement of purpose and service users guide that provides all relevant information for the resident and their relatives. The manager or the deputy manager of the home undertakes a pre admission assessment of all potential residents, and will visit them at home or in hospital as necessary, to ensure that the home is able to meet their identified needs. The homes’ service users guide states that the first four weeks of residence is on a trial basis, and may be terminated with one weeks notice by either party, so that all concerned are sure that the resident is happy with the placement. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10 The arrangements for meeting resident’s health care needs was variable with some areas of failure. The current management of pressure sores within the home poses a potential risk for some residents. The varied standard of the procedures for medicine administration may result in a potentially poor outcome for some residents. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Individual care plans were available for all residents, and three of these were examined. Generally, the plans were comprehensive, identified needs and the appropriate care management, easy to understand and included residents’ preferences. The care plan for a resident who had a pressure sore had not been updated following the visit to the home by the Tissue Viability Nurse. Although the recommended management of the sore was instigated, the care plan did not reflect this. There was no documentation to accurately monitor the healing progress of the sore in the care notes. The manager had recently carried out an audit of the residents who have pressure sores in the home, and concluded that there is a need for further training for staff, to ensure that they are managed appropriately, and relevant documentation is regularly reviewed and kept up to date. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 10 A nutritional assessment had been completed, but the resident had not been weighed as they were unable to use the sit-on scale. It was recommended that a mid arm circumferential measurement be used as an alternative to monitor any weight changes. Visits to the home by GP’s, Tissue Viability Nurse, Chiropodist, Dentist and the Optician are recorded appropriately. The medication is stored appropriately and there were policies and procedures in place for the administration and self -administration of medicines. It was recommended that the manager records daily, both the minimum and maximum temperatures of the drug fridge. Generally the administration of medicines in the home is good, although the standard has fallen slightly since the previous inspection. A discrepancy was found in the counts of two of the boxed medicines, and an item on one Medicine Administration Record (MAR) chart and the accompanying prescription did not accurately reflect the current dosage being administered as prescribed by the GP. Regular audits are carried out by the manager and the deputy to monitor standards of medicine administration in the home. Care staff were observed to address residents with respect, and to knock on residents bedroom doors before entering. One resident said “ All the staff are kind and polite to me”. A residents’ relative said “ The staff are very kind, and they treat my mother with respect. She always looks well cared for”. One visitor said “My relative cannot speak, and sometimes his buzzer is not put in reach. He always looks clean and tidy and they care for him well.” Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 & 15 Overall Dietary needs of residents are well catered for with a balanced and varied selection of food available , that and promotes their well-being. The systems for consultation with the residents in the home are good, with their views both sought and acted upon. The activities provided for residents generally matches their expectations and preferences, thus contributing to their quality of life and independence. EVIDENCE: The preferences of residents in respect to their daily routines were recorded in their care plans. One resident said” I can get up when I like, and sometimes don’t go to bed until quite late” One resident goes out regularly to go shopping, and uses the Ring and Ride service. Residents spoken to said that a range of activities are arranged for them, including trips out and entertainers coming in to the home. One said” We had a game of bowls on the lawn one day last week, as the weather was so nice”. A game of darts was being organised on the day of the inspection. Visitors are welcomed to the home at any time, one said ”I visit my relative sometimes two or three times a day, and am always made welcome”. The residents’ bedrooms contained many personal items and reflected their personal taste. A varied and nutritious diet is offered in the home, the four weeks menus supported this, and the residents are consulted regarding the meals on the Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 12 menu. Only one choice of main course is offered on the menu, however staff and residents spoken to confirmed that if they did not like what was on the menu for that day, an alternative was provided. The menu states that specialist diets, such as vegetarian or diabetic, can be catered for when needed. One resident said “ The food is generally good, but today the cauliflower is too hard”. Discussions with the manager and the residents revealed that all the vegetables used in the home are frozen. Some of the residents said that they would like to have some fresh vegetables as they usually have more flavour. Fresh fruit was available. Hot beverages are available throughout the day or upon request. There are three dining areas in the home, and some residents choose to eat in their bedrooms. Tables were appropriately laid and seating was comfortable. One resident chose to sit in her wheelchair at the table for her meal. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 13 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 & 18 The home has a satisfactory complaints procedure that is accessible to residents and visitors so that they are aware of how to make a complaint ensuring the promotion of protection matters. EVIDENCE: The home had recorded one complaint since the previous inspection. The log showed the progress of the complaint, the action taken and the fact that the complaint was resolved. The complaints policy and procedure includes all the information required to enable a person to make a complaint if they should wish to do so. One resident said “I would never feel frightened of making a complaint, but we usually manage to resolve problems at out resident meetings.” The adult protection policy and procedure incorporated the Birmingham Multi Agency Guidelines. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,& 26 The standard of the environment within this home is very high, providing residents with an attractive, safe and homely place to live. EVIDENCE: Marian House is purpose built, is accessible by wheelchair, and provides a very homely environment for the residents to live in. All residents have a single bedroom, some with en suite, and there are ample communal assisted bathing and toilet facilities. All areas were very clean and there were no offensive odours. Bedrooms contained residents’ personal possessions, and were comfortable and clean. All areas were decorated to a high standard. There were aids and adaptations available to help promote independence where possible. The passenger lift and aids were regularly maintained to ensure safety in use. There is a private walled garden for residents to sit out in, and this was very attractive and tidy. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 15 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 Overall the arrangements for staffing the home are sufficient to meet the needs of the residents, to ensure health and wellbeing, in most cases. The inconsistency of the management of residents with pressure sores may place some residents at risk. The robust recruitment procedure protects the residents. EVIDENCE: There were two trained nurses and seven carers on duty on the first day of the inspection, plus the manager and deputy who were working as supernumerary. Staffing rotas identified that these levels of staff are maintained in most instances. There was a very high ratio of the staff that are trained to NVQ2 or equivalent, that helps to contribute to a high standard of care. One resident said “ The staff look after me very well, and they are always very obliging” There is a robust recruitment procedure for all new members of staff, and all necessary checks and documentation were present in the staff files examined. Staff spoken to confirmed that they had undergone a formal induction process, and records were present in staff files. There is a comprehensive training programme in place, and all staff receive updates of statutory training, including moving and handling, cross infection and health and safety. Additional training is available for all staff, and includes, Tissue viability, Dementia Care, Communication, Falls in the Elderly, and Caring for the Dying and their Families. The manager had identified the need for staff to undergo further training in Tissue Viability and the management of pressure sores, and a session has been booked to be delivered by the Tissue Viability Nurse. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 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) 31,32,33,36,37 & 38 The home has good systems for consultation with residents where their views are both sought and acted upon. The management style of the home engenders an open and inclusive atmosphere The homes’ generally high standard of record keeping safeguards the residents’ rights and best interests. The high standard of attention to the health and safety issues for staff and residents help promote and protect their health and welfare. EVIDENCE: The Registered Manager is a qualified nurse with many years experience of managing a care home, and has engendered an open and positive atmosphere in the home. There is a formal quality assurance programme in place to obtain the views of staff, residents and other health professionals about the service offered by the home. Regular questionnaires are sent out and the results are analysed and used to improve the service in areas identified. Minutes are kept of the residents and staff meetings held. Some residents take a very active Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 17 part in their meetings. There were records that staff had received regular supervision sessions. Health and Safety checks in regard to equipment used at the home, and the environment generally, are carried out regularly and maintenance documentation and records were up to date. During the tour of the home, the following were noted. The key had been left in the sluice door, and the laundry door was open, although it was in use but there was no staff member in attendance. One residents’ bedroom door had been wedged open. It was noted in the residents care plan that she preferred her bedroom door open, as she felt claustrophobic with it shut. However, a suitable automatic closure connected to the fire alarm must be fitted, to ensure the safety of this resident in the event of a fire occurring. Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 18 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 3 x 3 x 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 3 2 Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 19 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 OP7 Regulation 15 Requirement The Registered manager must ensure that the care plans are updated to accurately reflect the current care needs of the residents, following the implementation of any recommendations by another health professional. The manager must take steps to ensure that the counts of boxed medicines are accurate and reflect the Medicine Administration Record (MAR) charts. The manager must ensure that the current prescription and MAR chart accurately reflect the dosage of medicine being administered as prescribed by the GP. The manager must ensure that the key to the sluice is not left in the lock when not in use. The manager must ensure that the door to the laundry is kept locked when in use, and no member of staff is in attendance. The manager must ensure that bedroom doors are not wedged open, to comply with fire safety. Timescale for action 12/6/05 2. OP9 13(2) 2/6/05 3. OP9 13(2) 2/6/05 4. 5. OP38 OP38 12(1)(a) 12(1)(a) 2/5/05 2/5/05 6. OP38 23(4)(a) 2/6/05 Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 20 7. OP38 23(4)(a) The manager must arrange for a suitable automatic door closure, connected to the fire alarm, is fitted to the bedroom door of the resident who wishes to have the door kept open for health reasons. 2/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that residents who are nutritionally compromised, and unable to use the sit on scale, should have a mid-arm circumference measurement taken regularly to monitor any change in weight. It is recommended that the manager records the minimum and maximum temperatures of the drug fridge, on a daily basis. It is recommended that a selection of fresh vegetable be introduced to the diets of the residents. 2. 3. OP9 OP15 Marian House Nursing Home e54_S24866_MarianHseNH_V226653_010605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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. 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