Inspection on 12/07/07 for Marie Louise House

This inspection was carried out on 12th July 2007.

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

Marie Louise House 11/07/08

Marie Louise House 16/05/06

Marie Louise House 10/01/06

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 Ms Wendy Thomas Key Unannounced Inspection 12th July 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 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.V341200.R01.S.doc Version 5.2 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 Mrs Kay Wendy Kelly 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) Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be over the age of 60 years. Date of last inspection 16th May 2006 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 open since May 2005. 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. Fees at the time of the visit to the home ranged from £720 to £870 per week. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contributing to this report comes from a range of sources including the Annual Quality Assurance Assessment (AQAA) returned by the home to the Commission for Social Care Inspection (the commission), a visit to the home on 12 July 2007, and other information submitted to the commission. During the visit to the home, which lasted eight hours, the inspector toured the home, spoke with the people living at the home, members of staff, visitors, the manager and the financial administrator, looked at care plans and inspected policies, procedures and recording relevant to the standards inspected. What the service does well: Most of the comments from the people living in the home were positive including, “The atmosphere here is so nice,” and, “You won’t find anything wrong here.” The home has an informative brochure providing details of the home to people considering living there. They can use this information to help them decide if this is the right home for them. People living at the home described their satisfaction with the activities programme on offer. Staff have time to escort people to the shops or for walks in the garden and local area. Pastoral care is provided by a sister from La Sagesse Convent who own the home. However the home is prepared to meet the spiritual needs of people from any denomination or religion. For some people this religious link plays a part in their decision to live at the home. The people living at the home said that if they had any problems they felt very comfortable discussing these with the deputy manager and manager. The home is clean and comfortable. It was noted that most people had brought furniture, pictures, and ornaments etc. from their previous homes to Marie Louise House with them to help them feel more at home and to keep familiar things around them. The staff at the home are conscientious about infection control and facilities for hand washing are available throughout the home. This promotes the helath and well-being of the people in the home and reduces the spread of infections. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 6 A good range of training opportunities are available to staff. They also have access to the Internet and trade journals to promote continuing learning and keeping up to date with relevant issues relating to the care needs of the people living at Marie Louise House. What has improved since the last inspection? What they could do better: Care plans must explain in detail how staff are to meet peoples’ needs, so that someone who doesn’t know them well would be able to support them properly. Care plans must be updated so that they give this level of detail for the person’s needs as they now are and not months or years ago. The home’s risk assessment and risk management processes need to be developed further so that risks are minimised for the people living in the home with the least restrictions to their freedoms and choices. There are ongoing difficulties in recruiting permanent staff, however the home maintains a good staff to resident ratio by using agency staff where necessary, and the manager was planning further recruitment. The people living in the home would like to have a constant team of staff they have got to know caring for them. The manager needs to ensure that she has sufficient information to form a sound judgement of prospective staff before employing them. Some staff references and application forms did not contain sufficient information to do this. This could put the people using the service at risk if unsuitable staff are employed. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 7 Since the last inspection care staff have received formal supervision, however this is not yet happening for the trained nurses. Staff practice should be monitored to promote best practice and ensure that the people living in the home are properly looked after. 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. The summary of this inspection report can be made available in other formats on request. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 8 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.V341200.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving to the home benefit from having plenty of information about the home on which to base their decision. They also have their needs assessed by staff so that home is clear that they can support those needs. EVIDENCE: The people living at the home said that they had been provided with plenty of information about the home to help them make the decision as to whether it would be right for them. They described being shown round by the manager and given the time to ask lots of questions. Those who moved in soon after the home opened could not remember having any written material, but the current version of the brochure was seen and includes a comprehensive statement of purpose and an informative service user guide as well as other Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 10 information about the home and any additional expenses. This provides good information on which people can make an informed judgement as to whether the home is what they are looking for. The current version was seen during the visit to the home and the manager confirmed that it is sent out to those enquiring about moving to the home. Discussion with the manager and files sampled, demonstrated that a nurse or member of the management team visited and assessed people planning to move to the home before they moved there. Assessments covered a wide range of needs and were in an informative narrative format. There were also nursing care needs assessments giving numerical scoring. When people first move into the home a member of the care staff spends time getting to know them and fills out an information sheet detailing their preferred daily routine and any particular likes and dislikes. This information provides the care team with sound information on which to base the person’s care. A member of the care team explained that they found this particularly useful as it gave them a chance to get to know the person. A relative recalled the manager visiting their relative in hospital to complete the assessment prior to their admission to the home. Not all of the assessments or the daily routines care plans were signed or dated, so it was not possible to sure that the information was still current. The home also provides respite care and that is clearly described in the information brochure. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although care plans include some useful information to enable staff to support the people who use the service effectively, improving the detail and making sure that care plans are updated as people’s needs change will enable people to have their needs met better and in the manner they prefer. The people living at the home benefit from staff who are mostly kind and respectful. EVIDENCE: All the people living at the home had individual files containing their care plans. These were kept in locked offices and also on computer. Individuals’ daily notes are now being kept on computer. It is the responsibility of both nursing and care staff to enter these. As required at the last inspection, the home had improved upon the care plans and included more information about how to support each individual. The level Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 12 of detail could be improved in these. For example, one care plan recorded that a hoist was being used, but it did not specify the type of hoist, sling and how the person liked to be supported to use it. Some peoples’ care plans contained examples of good practice. The “daily routines care plans” and some of the “night care plans” contained a good level of detail in a narrative format, which clearly explained how the person liked to be supported. Each person’s file contained a range of care plans and those seen were all being reviewed monthly in line with good practice. However, as people’s needs changed, the care plans were not always being updated to reflect this. New carers would normally refer to the care plan to determine how to support the person and this could be different to what the reviews showed the person now needed. The care plans must be updated to show that the current needs of the person are described and what the carer needs to do to support these. There was no management tool in place to monitor whether this was being done. Good practice principles say that the person themselves, and if appropriate, their relatives should be involved in drawing up and developing their care plan. The manager assured that inspector that this was happening and said that people living in the home and their relatives were signing care plans to say they had been involve in this way. One relative spoken to was aware that they had had discussions with the manager about their relative’s care, however the people living in the home spoken with could not recall any involvement. However they were very satisfied with their care and did not feel the need to be more involved in their care plans. The manager, in the Annual Quality Assurance Assessment (AQAA) she returned to the Commission for Social Care Inspection, confirmed that the home had a procedure for the control, storage, disposal, recording and administration of medicines, and that it had been reviewed in May 2007. These procedures were observed in practice at the last inspection and were found to be satisfactory. There had been no records of staff training in the control, storage, disposal, recording and administration of medicines at that time. These are now being kept and were sampled during the visit to the home on 12 July 2007. Most staff were observed to knock before entering the rooms of the people living in the home. Staff were observed to treat the people living in the home with respect and kindness. All those seen were polite and friendly towards the people living there and their visitors. One person described how they liked to left in the bath for a while, after they had been helped to get in, and that staff complied with this. One visitor commented that when supporting their relative, staff sometimes carried on their own conversation and did not include the person to whom they were providing care. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 13 Although the likelihood of falls had been assessed for each person, there were few other risk assessments of people’s files. For example, some people had bedsides up on their beds at night, but there were no risk assessments weighing the potential risks against the potential benefits. The doors to the bedroom area on the ground floor were kept locked, but there were no risk assessments to demonstrate what the benefits were of restricting people’s freedom in this way. Risk assessment and risk management strategies for the people living in the home should be developed further. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Marie Louie House benefit from an organised activities programme, and also from staffing levels that enable them to spend recreational time with care staff. The religious link in the founding of the home means there is an ethos in place that seeks to meet a person’s religious needs, whatever they may be. EVIDENCE: Following a requirement in the previous inspection report, formal supervision sessions for care staff has much improved with the manager and staff confirming that supervision is now taking place every two months. Nursing staff were not receiving supervision and this must now be implemented. Various people who lived at the home described activities they enjoyed doing including arts and crafts sessions where they could make things, exercise sessions, film afternoons, visiting musicians and entertainers, and going for one-to-one walks with the activity coordinator. Each week an activity schedule is circulated to everyone, as well as one being on display in the entrance area. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 15 During the week of the visit, other activities included, reminiscence, puzzles and quizzes, birthday parties and communion. Accounts of the activities were positive and those spoken with were happy with the range provided. Staff spoken with said that they had time to sit and chat with people, do their nails, or walk with them to the shops. The people living in the home also described this, and appreciated this time, although one observed that the staff were very busy in the mornings. The people living at the home described being able to participate in activities, spend time on their own, have visitors, or mix with their friends in the home as they wished. Lunch was served in the dining room, but those who wished said they could have it in their rooms. The manager described an outing the home had arranged the week before for four of the people living there to go on a boat trip. A member of staff explained that sometimes theatre trips would be booked, and on several days a small group of people would have support to see a show. There is a full-time activities coordinator and the manager explained that they were doing further training to enable them to develop the activities further, especially those for people with dementia. The manager also explained that someone from a local history group comes and gives talks at the home. She said that these were always well received and well attended. The manager described plans to build links with other local organisations. The home is owned by a Roman Catholic religious order, the Sisters of the Daughters of Wisdom and managed by an organisation based on Christian principles, the Hospital Management Trust. One of the sisters from La Sagesse convent next door provides pastoral care for the home and meets those living there on a one-to-one basis if they wish. Although the home is grounded in a Christian ethos, people of any denomination or religion are welcome to live there. Currently Roman Catholic and Anglican services are held at the home, but other religions and denominations would be provided for upon request. The Christian presence is not overt and those living there and the staff follow their own particular religious persuasion, or none, if they wish. One relative said that for them the religious connexion was positive and had influenced their choice of home for their relative. During the day of the visit to the home there were a large number of other visitors to see individuals living there. The manager confirmed that the people living there receive lots of visits from friends and family. Those asked said that they had visits from family or friends, and said that they would sometimes invite them to stay for lunch at the home. People described being happy in the home and with the choices they were able to make. One said that they were “very contented” Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 16 Opinions about the food were generally very good, including “we have very nice meals,” “It’s pretty good,” and “It’s okay.” The manager explained that they would soon be having a “special food evening” and orders were being taken for fish and chips, Chinese, Indian, pizza or kebabs. On the day of the visit to the home the lunch looked appetising and people said they were enjoying it. There is always a choice and someone living there confirmed that if they didn’t want either choice, they would be provided with something else. One person said that they didn’t always get what they had ordered. The manager explained that the head and assistant chefs are currently undertaking an e-learning course to further enhance their understanding of the nutritional needs of people living in care. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at the home knew what to do if they had any concerns or complaints. Their safety and well-being was promoted through staff training in relation to safeguarding vulnerable adults. EVIDENCE: The complaints log was seen and any complaints were being dealt with appropriately. A summary of the complaints procedure was available in the information pack sent to people considering moving to the home. Although the people living in the home asked about it, did not know the complaints procedure they all felt confident in bringing issues to the attention of the manager or deputy manager. And as one person put it, “If the worst came to the worst we could talk to the owners.” A member of staff was able to explain the complaints process and explained that if a complaint were brought to them they would try and resolve it before referring it upwards. The manager said that she operates an open door policy and she would like to think that people could approach her with any concerns at any time. The people living at Marie Louise House felt comfortable and safe there. Staff described having had training relating to safeguarding vulnerable adults. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Marie Louise House benefit from a clean and well-kept home and have been able to individualise their own rooms. EVIDENCE: The home was purpose built and opened in May 2005. It is in a good state of repair. Many of the people living in the home had taken in items of their own from their previous homes to make their rooms more homely. Those asked about their rooms were happy with them, although one found it a bit cluttered with all the equipment they needed for their care. All bedrooms have an en suite toilet and washbasin. Three also have a shower. Five specialist baths are available in the home for those who require assistance getting into and out of the bath and/or in the bath. Those asked were happy with the bathing arrangements. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 19 One of the people spoken with said, “As soon as I came through the door I thought how nice it was.” They went on to add that, “It never smells like a home like some do.” During the afternoon a film was being shown on the television in the downstairs lounge. There are further lounges on the other two floors and a lounge/diner in the bedroom area of the downstairs unit. All have comfortable seating, a television and views over the garden. The reception areas on each floor also have comfortable seating. There is a large dining room on the ground floor adjacent to the kitchen, where those who wish can eat lunch. There is a small oratory for quiet and prayer. The laundry is also on the ground floor and the manager and person working there agreed that although the washing machine and tumble drier were kept working flat out, they could manage to meet the needs of the home. Bed linen is sent to an outside laundry service. The people living in the home and the staff said that there were the occasional mix-ups with laundry, but the home provided name labels and any problems were usually sorted amicably. Doors from the ground floor lounge and dining rooms open onto the garden. There is a paved area immediately infront of the house. Some outdoor furniture has just been obtained so that people can sit out here in fine weather. One person was sat out there during the visit. There is an area of lawn and then a wild flower meadow/nature garden belonging to the convent, but providing a pleasant outlook for the home. The manager, in the AQAA, described good hand washing and infection control procedures in the home. Hand sanitising equipment was observed at strategic points throughout the home. Staff were seen to be using this. One of the people living in the home particularly praised the staff for their cleanliness suggesting that they must ”wash their hands 1000 times a day.” The home has a team of cleaners who were seen at work during the morning. The home looked clean and well kept throughout. Opinions of those living there included, “It’s very clean” and, “you couldn’t get it any cleaner.” A member of the care staff confirmed that gloves were available in all rooms to promote infection control and that baths were cleaned after each use. They also explained the precautions taken to prevent cross infection, demonstrating the home’s commitment to implement good practice. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Marie Louise House benefit from a well trained, caring staff team. Despite difficulties to recruit staff, there are sufficient staff on duty at all times to meet the needs of those living there. The recruitment process needs to be more thorough to ensure that staff a suitable for the work and that the people living there are safeguarded from abuse. EVIDENCE: The manager, in discussion and in the AQQA, said that there were ongoing problems in recruiting suitable calibre staff. At the time of the visit to the home there were 10.2 care staff vacancies, and although some permanent staff work extra shifts to cover, the home also uses agency staff. The people living in the home found this a problem, “Staff change a lot… they’re always different… I don’t get to know them.” The manager explained that where possible they tried to use the same agency staff and build up consistency. The staff were valued by the people living in the home, who said such things as, “the staff are so nice,” “the staff are wonderful,” “they always help if I want it,” “on the whole they are very nice” and, “they do their best.” A visitor observed that, “the carers are very caring.” Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 21 The manager reported that in order to try and overcome the staff shortage she would shortly be going to Poland to recruit staff. Permanent staff explained that using agency staff wasn’t always satisfactory. Although the rota showed sufficient nursing and care staff availability over the weekend, one visitor’s perception was that fewer staff were available at weekends, and that more were needed. There are nine permanent qualified nurses and 19 permanent care staff. 18 of the care staff are qualified to at least NVQ 2. The staff supplied by the agency do not have qualifications. Documentation was seen from the agency confirming each member of staff’s training, experience and recruitment checks (references and Criminal Records Bureau check). However some mandatory training such as moving and handling was out of date. The manager confirmed that she now has lists of what training staff have had and when mandatory training is due for renewal. Copies of certificates verifying that staff have attended training are being kept. These were sampled during the visit to the home. The home now uses an e-learning system where staff can access a training programme via the Internet. Staff confirmed that they have time during their working hours to access this, or if they have access to the Internet at home they can work from there if they prefer. The manager finds the system successful and is pleased with the use the staff team have made of it. A member of staff also praised the system and added that training courses were always available. As well as mandatory training such as manual handling and first aid a member of staff also described attending training relating to the needs of the people using the service, such as working with people who have suffered a stroke, palliative care and caring for people with dementia. A visitor commented that they would have expected staff to know about the particular medical condition experienced by the person they were visiting. Staff recruitment records were sampled. All staff had completed an application form and attended an interview. References had been sought, but in some cases these were brief and did not provide sufficient evidence that the person was suitable for the work. In one file sampled there was no explanation for a gap in a person’s employment history. Pre-employment checks with the Criminal Records Bureau were being carried out, but the need to follow robust recruitment practices to ensure the safety, well-being and protection of the people using the service was discussed with the manager. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Marie Louise House benefit from being consulted by the organisation about the management of the home and by having an approachable in-house management team. Systems are in place to keep them safe and to keep the home well maintained. EVIDENCE: Comments by the people living at Marie Louise House about the management team were complimentary. Several mentioned the approachability of the deputy manager and one said that they could tease the matron, indicating a Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 23 positive relationship. People living there said that the home had improved and was getting better. The Hospital Management Trust has a quality assurance programme that is followed in all its homes. This involves an annual survey of the people living in the home, which is sent out and returned to the organisation’s headquarters. Where it is analysed and a report sent to the home. The results are discussed between representatives of the home, the Hospital Management Trust and the Sisters of the Daughters of Wisdom. The home has monthly management meetings involving the Director of Care Homes and the Financial Director from the Hospital Management Trust, and the Manager and financial Administrator from the home. They develop and monitor the annual business plan. It was also reported that the organisation had just carried out a food audit of all its homes, which involved consultation with the people living there. The report on the outcome of this was still being prepared. There is a system in place to support those people who do not look after their own money. The financial administrator manages this and keeps records of deposits and withdrawals. The records and amounts held were sampled, and those held were correct. Following a requirement in the previous inspection report, formal supervision sessions for care staff has much improved with the manager and staff confirming that supervision is now taking place every two months. Nursing staff were not receiving supervision and this must now be implemented. There is a need for management tools to be developed for the monitoring of staff performance and to quality assess the systems in place in the home. The home’s AQAA confirmed that health and safety checks are being done and plant and equipment is being maintained and serviced as recommended by the manufacturers. Fire detection and alarm systems are being tested and maintained. The fire alarm system was tested during the visit to the home. Some staff expressed concern about not being able to hear the alarms. The maintenance person arranged for the fire company to come and review this. The manager explained that the home has started holding six-monthly health and safety meetings with representatives from all staff groups in the home and from the organisation’s head quarters. Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 25 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 (1) Requirement Care plans must contain enough detail for staff unfamiliar with the person to be able to support them successfully. This is a partial repeat requirement from the last 3 inspections. Timescales of 18/07/06, 30/9/05 and 01/03/06 were not met. 2. OP7 15 (2) Care plans must be updated, as the person’s needs change so that they are always up to date. Thorough pre-employment checks, such as obtaining references and complete employment histories, must be carried out to safeguard the people in the home from people who may not be suitable to work with them. The manager must ensure staff receive formal supervision by an appropriately trained line manager 04/10/07 Timescale for action 04/10/07 3. OP29 19 09/08/07 6. OP36 18(2) 04/10/07 Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 26 This is a repeat requirement from the last inspection report. The timescale of 18/07/06 was not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marie Louise House DS0000062154.V341200.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V341200.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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