Inspection on 10/01/06 for Marie Louise House

This inspection was carried out on 10th January 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

Marie Louise House 11/07/08

Marie Louise House 12/07/07

Marie Louise House 16/05/06

Marie Louise House 09/08/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Marie Louise House Newton Lane Romsey Hampshire SO51 8GZ Lead Inspector Sue Maynard Unannounced Inspection 10th January 2006 09:15 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 Marie Louise House DS0000062154.V277175.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. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marie Louise House Address Newton Lane Romsey Hampshire SO51 8GZ 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) 01794 521224 01794 526310 The Hospital Management Trust Care Home 46 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (46), Physical disability (10), Physical disability over 65 years of age (10), Terminally ill (5), Terminally ill over 65 years of age (5) Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be over the age of 60 years. Date of last inspection 9th August 2005 Brief Description of the Service: Marie Louise House is a home for 46 service users situated in Romsey. The home is owned by the Daughters of Wisdom and leased to a registered charity, the Hospital Management Trust. The home has been built on the site that was previously occupied by La Sagesse school. The building has been designed to provide the service users with single en-suite accommodation and has been decorated and furnished to a very high standard. The gardens have been landscaped and provide areas of privacy for service users to sit. The home places emphasis on the pastoral care that is provided by the Daughters of Wisdom who live in the convent alongside the home. Service users of all denominations are accommodated in the home. The home has a large car parking area and is within walking distance of Romsey town centre. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a second unannounced inspection that took place on 10th January 2006. At the previous inspection requirements were made. This inspection is to establish that the requirements have been met. One inspector conducted the inspection, which lasted for six hours. The inspector met with the new manager for the home who had only been in post for five days. The home has been without a permanent manager for some time following the resignation of the previous manager. There has been a temporary manager in post who has been supported by a temporary deputy manager, following the resignation of the deputy manager in December 2005. There have been other changes to the staffing structure in the home and some systems in the home have not been monitored closely. It is hoped that with the appointment of the new manager and a deputy manager that the home will move forward and the areas identified in this report, as not fully meeting the minimum standards, will be addressed and improved upon. During the inspection the inspector spoke to five residents and a visitor to the home. The inspector also spoke to one of the Sisters from the convent that provides pastoral care to the residents in the home. Three members of staff were also spoken to. What the service does well: What has improved since the last inspection? What they could do better: The reviewing and updating of many of the documents has to be addressed. Care plans are not personalised and do not address the individual needs of the each resident. Residents are not receiving social and recreational input since the person who was responsible for this has resigned. Residents were left alone left in communal areas for periods of time and had no access to a nurse call bell. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 6 Care staff employed by the home is below the minimum recommended number on many shifts. Staff from a care agency currently covers these shortfalls. The staff training has not been undertaken recently due to the trainer for the home having to undertake another role in the home. Training for the staff is due to be re-commenced with the forthcoming weeks. 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. Marie Louise House DS0000062154.V277175.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 Marie Louise House DS0000062154.V277175.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): 1 and 3 The current Statement of Purpose does not provide prospective residents with up to date information that will enable them to make an informed choice about the suitability of the home and their decision to live there. All prospective new residents care needs are assessed prior to admission to the home but an improved format of the assessment would ensure that sufficient details are obtained to assure residents that all their care needs will be met. EVIDENCE: The Statement of Purpose for the home was not initially available to the inspector. A copy was eventually found and on examination this was found to contain out of date information. The document was dated August 2005 and did not reflect the changes in management that have taken place since the home was opened. It did not include a copy of the home’s complaints procedure and the contact details for the Commission were not documented. The inspector was later shown a company brochure with information about the home. The inspector was told that a copy of this is given to all new residents and members of the public who are making enquiries about the home. The Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 9 brochure contained a copy of the out of date Statement of Purpose and did not contain the home’s complaints procedure. The brochures were not on display in the reception area of the home. Members of the public would not be aware that they were available. It was also noted that a copy of the last inspection report was not available in the reception are of the home. In fact the manager was not aware of the report and had to ask for assistance to find it. Eventually a draft copy of the report from August 2005 was found but a copy of the final report was not available. The manager had only been in post for five days and had at that time not read the report from the last inspection. The inspector discussed with the manager the lack of availability of the Statement of Purpose and the last report for residents and visitors to the home. She has agreed to update the Statement of Purpose and will place copies in reception areas on each floor of the home together with a copy of the inspection report. The inspector examined copies of the pre-admission assessments undertaken for four residents prior to their admission to the home. Two of the assessments were detailed and contained sufficient information for the decision to be made that the needs of the prospective resident could be met. The remaining two assessments contained very little information and would not have formed a basis for establishing the ability of the home to provide appropriate care for the resident. The manager confirmed that she or her deputy would be undertaking all future pre-admission assessments and that the format of the assessment will be changed to provide more space for the assessor to write information about the prospective resident. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 10 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 The care plans do not reflect the individual health, personal and social needs of the residents to ensure that their personal needs are met. EVIDENCE: The inspector examined the records for four residents. All the record files had the personal details of each resident taken on admission to the home, namely, contact details for next of kin, date of birth and date of admission to the home. The name of the residents doctor and, where appropriate, the name of the resident’s care manager. Care plans were in place for all the residents but these were not detailed or personalised to address the individual care needs of each resident. The care plans were “core care plans” which staff had completed by ticking a box in each section of the plan. There was a section at the bottom of each plan for additional information; all these had been left blank. The documented medical history of some of these residents should have generated a very specific care plan to address particular care needs. None were seen. Risk assessments for tissue viability, nutrition and falls were seen but in two instances had been assessed incorrectly. In one assessment the resident’s medical condition had not been taken into account when the assessment was Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 11 initially undertaken. If this had been undertaken correctly, the residents would have been placed at high risk and not medium risk as identified in the records. For residents assessed as being at high risk there were no action plans in place to address the risk and how it would be managed. None of the records seen by the inspector contained a care plan for night care/sleeping. All the records contained a form to be signed by the resident or their representative to say they had been involved in the care planning process. All these forms had been left blank. At the last inspection the inspector had been informed that the care planning for the home was shortly to be documented on a computer and that the care plans at that time were just temporary. No progress appears to have been made with the care plans and the requirement made at the last inspection has not been not been met. The new manager for the home is aware of the unsatisfactory documentation of care plans in the home and has already identified this as a priority to be addressed as part of her management strategy plan. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 12 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 The lack of management of the social activities in the home does not create a positive, varied and interesting life for the residents, which meets their expectations for living in the home. EVIDENCE: The activities co-ordinator who was employed at the time of the last inspection has now resigned and the home has been without a member of staff to take responsibility for this for some time. On the day of this inspection it was noted by the inspector that the majority of the residents were in their rooms. A few residents were in the communal lounge areas. There was no evidence of staff interaction with these or any of the other residents. None of the residents in the lounge areas had access to a nurse call bell and one resident was calling for a nurse for some time before a member of staff heard her calls. The inspector spoke with residents in their rooms who said that the staff were attentive and kind. Two of the residents stated that they were bored and they found the hours long especially in the afternoons and evenings. They said that staff were always so busy and never had time to talk to them except when they were receiving care from them. The Sisters from the nearby Convent continue to visit the home daily and speak to the residents and clergy from local churches visit the home regularly. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 13 The new manager told the inspector that the home is advertising for a new activity co-ordinator and that until one is appointed she would be taking responsibility for organising some recreational and social activities for the residents. The residents’ records did not record the personal preferences or life history. The manager is aware of this and will be addressing this as part of the revision of the care plans and residents’ records. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 14 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 Accurate records of complaints made to the home are not maintained to provide evidence that complaints are acted on appropriately. EVIDENCE: Examination of the complaints record for the home showed that one complaint had been received by the home. The outcome of the complaint was recorded but there was no record of who investigated the complaint and what the response to the complainant was. There was no record available to say if the complainant had been spoken to. Residents spoken to during the inspection confirmed that they would speak to the manager if they had any concerns about their care. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 15 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): Standards 19 and 26 were not assessed during this inspection. EVIDENCE: Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 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): 27, 28, 29 and 30 The numbers and skill mix of staff meets the residents’ care needs are met at this time by the home employing staff from a care agency. The recruitment procedure for the home ensures the vulnerable people living in the home are protected. The lack of a formal programme over several weeks has not enabled staff training to be effectively monitored and ensure they are competent to do their job. EVIDENCE: On the day of the inspection the manager confirmed that agency care staff were employed to meet the shortfalls in staffing numbers. These staff were not recorded on the staffing rota, which gave the impression that the incorrect number of staff were on duty. The rota for the following week also showed that insufficient staff would be on duty. The manager confirmed that she would be employing agency staff to cover these shortfalls. One resident told the inspector that she always seemed to have a different nurse every day to provide her care. She commented that the staff were kind, but she would like more continuity by having the same nurse every time to enable her to get to know them and the nurse to get to know her. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 17 Some staff employed by the home has completed their training for NVQ level 2 but at this time this number is under the required 50 that should have completed the training by the end of 2005. The home employs a training co-ordinator who explained to the inspector that all training in the home was temporally suspended for some weeks, as she had to take on the role of deputy manager until the current manager was in post. She confirmed that the training programme is to re-commence this month. A copy of the programme was supplied to the inspector. The inspector examined copies of four staff recruitment records. These were all found to be in order. There was evidence that written references had been obtained, application forms had been completed and evidence of personal identification was available. Appropriate checks had been undertaken with the Criminal Records Bureau and the Protection of Vulnerable Adults register. Work permits had been obtained from the Home office where necessary. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 18 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): Standards 31,33,35 and 38 were not assessed during this inspection. EVIDENCE: Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 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 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 20 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 Standard OP1 Regulation 4(1) Requirement The registered person must make available to residents and up-to-date statement of purpose with the aims and objectives, and must state the services provided by the home. The registered person, in consultation with the resident must set out a written as to how the needs in respect of health and welfare of the resident are to be met. This requirement was made at the last inspection with a timescale of 30-9-05. The home must provide a routine of daily living and activities that is flexible and varied to meet the residents’ expectations and preferences. The home must ensure that there is a clear complaints procedure which specifies how complaints may be made and who will deal with them with an assurance that they will be responded to within a maximum of 28 days. The duty roster must record the DS0000062154.V277175.R01.S.doc Timescale for action 01/03/06 2 OP7 15(1) 01/03/06 3 OP12 16(2) 01/03/06 4 OP16 22 01/03/06 5 OP27 Schedule 08/02/06 Page 21 Marie Louise House Version 5.1 4 (7) 6 OP28 18(1)(c)(i ) names of the staff that have actually worked. Persons working in the home 30/06/06 must receive training appropriate to the work they are to perform. 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 OP3 Good Practice Recommendations The format of the pre-admission assessment form should be re-assessed. Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Marie Louise House DS0000062154.V277175.R01.S.doc Version 5.1 Page 23 - 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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