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

This inspection was carried out on 6th January 2006.

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 Nursing Home 20/08/07

Marian House Nursing Home 24/10/06

Marian House Nursing Home 01/06/05

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 West Midlands B76 1JA Lead Inspector Elizabeth Mackle Unannounced Inspection 10.50 6 January 2006 th 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 Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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 Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marian House Nursing Home Address 32 Walmley Ash Road Walmley Sutton Coldfield West Midlands B76 1JA 0121 240 8000 0121 240 8039 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) Walmley Care Home Limited Miss Josephine Louise Stinton Care Home 35 Category(ies) of Physical disability (35), Physical disability over registration, with number 65 years of age (35) of places Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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. 1st June 2005 Date of last inspection 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 is 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 assisted 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 DS0000024866.V277181.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook the unannounced inspection on 6th January 2006. The Registered Manager was present in the home throughout the inspection and assisted in the process. The inspector had the opportunity to speak with three residents (one of whom is the Service User Representative), three relatives, and four members of staff. Information was also gathered by discreet observation of staff performing their duties. Care records for three residents were sampled. The personnel records for three staff members were checked, together with the complaints register and other relevant documentation. A tour of the building was conducted and the majority of bedrooms seen. Plans are well advanced in relation to an extension that would afford an additional six beds (bringing the total number of places to 41), an extra lounge and new laundry facility. The expected date of completion of this work is currently autumn 2006. What the service does well: Marian House continues to provide a very pleasant, clean and well maintained environment for residents. Residents’ rooms were comfortable and homely. Although the activities organizer is at present on extended leave, there is a range of activities available to residents. Residents are involved in the running of the home. Meetings between staff and residents take place three times a year, and this together with the role of Service User Representative ensures that residents’ views can easily be obtained, considered and acted upon. Residents and relatives reported favourably on life in the home, and were generally happy with the service provided. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 6 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 Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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 Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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): 1 and 3 The statement of purpose and service user guide required some updating to enable prospective residents, relatives and external professionals to make an informed decision about the home. Pre-admission assessment documentation needs to be more fully completed in order to assess the home’s ability to meet all identified needs. EVIDENCE: Both the Statement of Purpose and Service User Guide were found to be comprehensive and provide useful information for residents and their families. The information in relation to staffing was found to be out of date and may cause some confusion. Of the three care records viewed, two were found to have incomplete preassessment documentation, particularly in relation to the “Social Profile” with the result that the care plan may not accurately reflect all the needs of the resident. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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, 10 Care records were found to be comprehensive, and the home had good working relationships with external health professionals and families helping ensure that the needs of residents were being met. More attention to detail in the pre-admission assessment documentation is required in order to provide the framework for the formulation of care plans. Observations of staff practices raised no concerns regarding the maintaining of residents’ privacy and dignity. EVIDENCE: The care records viewed were generally found to be comprehensive and included evidence of an individual plan of care, regular review, appropriate risk assessments, daily entries and record of professional visits. In care records viewed the Social Activities Section was found to be out of date, and in one case not completed. In two cases the pre-admission documentation was found to be incomplete in relation to Social Profile and the nurse completing the assessment had not signed it. It was clear that, where possible, residents and relatives are consulted about care issues. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 10 The Service User Representative discussed her role within the home and said “the staff work very hard; there is an open culture. “I am able to observe and can point out how things might be done better”. Residents and relatives who conversed with the inspector confirmed that they are treated with respect and courtesy. A large number of relatives/friends were visiting residents at the time of the inspection, and there was a relaxed, open and welcoming atmosphere in the home. Staff and visitors were observed to be communicating in an appropriate and friendly manner. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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): 12, 13, 14, 15 Residents felt able to exercise in choice all aspects of their daily lives, and felt that their views would be taken into account with a view to improving their quality of life. Meals are provided offering choice and variety, and special diets are catered for. EVIDENCE: The relative of one resident said “I am very happy with the care”. She confirmed that arrangements had been made for the resident in question to receive regular visits from her minister of religion. The menu offered to residents operates on a four-week cycle and offers choice and variety. Residents have a choice of main meal, and the menu includes a range of fresh vegetables particularly at weekends. One resident commented “I would like to see more fresh vegetables during the week”, and another said “the food’s very good here”. There were no restrictions imposed on visits, and it was clear throughout the inspection that family members and friends visit the home and are made to feel welcome. A number of residents confirmed that they are encouraged to maintain links with community networks as they wish. One resident said “I go to church locally, and also attend a luncheon club”. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 12 Although the Activities Organiser is at present on extended leave, the home nevertheless has a planned programme of activities running throughout the year. These include events such as Music and Movement, Sing-along, visits from a local church choir. The manager had carried out a consultation exercise with residents asking them what type of activities they would like to be made available. One resident said “I am mainly happy, but there are not many activities going on”. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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 the following standard(s): 16 The home’s complaints procedure, “open” culture, role of Service User Representative, and good channels of communication all help ensure that residents views and opinions are sought and acted upon. EVIDENCE: Within the home the Administrator is the dedicated Complaints Officer and first point of contact for complainants. If the complaint is in relation to clinical care this is dealt with by the Clinical Manager. The Complaints record was viewed, and three complaints had been received since the last inspection. These had been resolved to the satisfaction of the complainant. The manager conducts a yearly audit of all complaints. The home also maintains a Comments Folder in which feedback and comments from residents and relatives are recorded. One resident commented that “there is an open culture here”, and a relative said “I am confident that any problems will be addressed”. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 23, 24, 25, 26 The home environment was clean, fresh and well maintained and this provides a comfortable environment for residents. Practices within the kitchen are not sufficiently robust to prevent the risk of cross infection. EVIDENCE: The home has all the necessary furniture and equipment to meet the needs of residents. The environment is clean, comfortable and free from malodours. The home is decorated and maintained to a high standard. Residents’ bedrooms were comfortable and homely, with personal possessions evident throughout. One relative said “the standards of hygiene are very high here”. Within the kitchen it was found that staff were not wearing suitable protective clothing, nor was any such clothing available for people entering the kitchen. The wearing of protective clothing at all times is essential to reduce the risk of exposing residents to cross infection. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 15 It was noted that some pre-prepared food in the fridge had not been marked with the date of preparation; this could potentially place residents at risk of being given food that is out of date. At the time of the inspection it was noted that there was no hot water in one of the first floor bedrooms; the manager agreed to resolve this as a matter of urgency. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 16 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): 29, 30 The home’s recruitment practices are satisfactory and help ensure that residents are protected. Training provided ensures that staff have the knowledge and skills to carry out their role effectively. EVIDENCE: The home’s recruitment practices in respect of staff directly recruited appear to be satisfactory, and staff undergo a range of checks, which help safeguard residents. A number of adaptation nurses within the home have been recruited through an employment agency. The Registered Manager is satisfied that the agency makes all necessary employment checks, and has received written confirmation from the agency to this effect. The staff register and Nursing and Midwifery Council registration records in relation to qualified nurses were viewed, and found to be in order. A relative said “the staff here are good and very approachable”. There was a good commitment to ongoing training for all staff, with individual training records, and Training and Development Plans in staff files. Courses available include all mandatory training, and in additional topics include Quality Assurance, Continence Care, Tissue Viability and Abuse in the Care Home. One member of staff said “we are very well supported by the manager, and she teaches us a lot”. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33, 37, 38 The home has effective management arrangements, and the open culture within the home, and good channels of communication, help ensure that the interests of residents are protected. Health and safety procedures are robust helping to ensure the safety and welfare of residents and staff. EVIDENCE: The Registered Manager is a qualified nurse with many years experience in managing a care home. The management culture in the home is open, inclusive and receptive to new ideas. The role of Service User Representative continues to prove very constructive in ensuring that the views of residents are canvassed and acted upon, and this development is viewed in a positive light by both staff and residents. There is a robust quality assurance system in operation, and the views of staff, residents, relatives and health professionals sought regularly, and feedback from interested parties informs practice in the home. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 18 The record of visits by the Responsible Provider that was available to the Inspector showed the last visit dated August 2005. The Registered Manager confirmed that the Registered Provider does visit the home on a weekly basis, but no records were available to the Inspector to evidence this. In keeping with the Care Homes Regulations it is necessary for the Registered Provider to visit the home at least once a month, to record the outcome of these visits and make the records available within the home. Residents meetings take place two or three times a year. Staff meetings are held on a 6 – 12 weekly basis, and minutes of both meetings are maintained in a clear and concise way. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 19 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 X 3 3 2 2 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X 3 3 Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No 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 1 Regulation 4 and 5 Requirement The Registered Manager must ensure that the Statement of Purpose and Service User guide are updated to reflect changes of personnel. The Registered Manager must ensure that pre-assessment documentation is fully completed and signed by the person conducting the assessment. The Registered Manager must ensure that catering staff wear suitable protective clothing at all times. The Registered Manager must ensure that all prepared food stored in the fridge is clearly labelled showing a description of the contents and the date of preparation. The Registered Provider must make available records of his visits to the home. Timescale for action 13/01/06 2. 3 14 (1) (a) 13/01/06 3. 26 13 (3) 06/01/06 4. 26 13 (3) 06/01/06 5. 33 26 (1) (3)(4)(5) 13/01/06 Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 21 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 12 Good Practice Recommendations It is recommended that the Registered Manager carries out ongoing monitoring of the provision of activities. Marian House Nursing Home DS0000024866.V277181.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Birmingham 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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