Inspection on 09/08/05 for Marie Louise House

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marie Louise House 11/07/08

Marie Louise House 12/07/07

Marie Louise House 16/05/06

Marie Louise House 10/01/06

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 Announced 9&10.08.05. 09:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Marie Louise House Address Newton Lane Romsey Hampshire SO51 8GZ 01794 521224 01794 526310 margaret@hmt-uk.org The Hospital Management Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Llinos Mair Hutchings Care Home 46 Category(ies) of Dementia - DE - 10 registration, with number Dementia - DE(E) - 10 of places Old Age - OP - 46 Physical Disability - PD - 10 Physical Disability, Over 65 - 10 Terminally Ill - TI - 5 Terminally Ill, Over 65 - TI(E) - 5 Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be over the age of 60 years. Date of last inspection N/A Brief Description of the Service: Marie Louise House is a home for 46 service users situated in Romsey. The home is owned by a registered charity,the Hospital Management Trust. The home has been built on the site that previously occupied by La Sagesse school. The building has been designed to provide the service users with single ensuite 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 Sisters 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 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Marie Louise House is a newly registered service and this was the home’s first inspection. The inspection was announced and took place over two days, 9th and 10th August 2005 and lasted a total of twelve hours. The registered manager and her deputy were available throughout the inspection. During the inspection the inspector was able to speak to residents and members of staff. On the day of the inspection there were eighteen residents in the home, the home has the capacity for forty-six residents. The manager explained that as more new staff are recruited the home will admit more residents. All of the residents spoken to by the inspector expressed their satisfaction with the care that they were receiving. All the residents said that the staff were very kind and considerate. Two residents spoken to, who had only recently been admitted to the home, expressed great sadness at having had to give up their homes to come into residential care. They emphasised that the staff had been very kind to them and had done everything possible to make them feel welcome and this had gone some way to making them accept that Marie Louise House was now their home. Members of staff spoken to said that they had undergone a very comprehensive induction programme before the home admitted any residents. They all said that the programme covered all aspects of care and that the programme was well structured and as a result of this they felt confident to be able to provide the residents with a high standard of care and that they would be able to pass on this standard to new staff that were recruited by the home. The inspector toured the environment and observed daily routines within the home. What the service does well: There is a very welcoming atmosphere in the home. The structure of the building has been well designed and takes into consideration the needs of both staff and residents as a comfortable and pleasant environment to both work and live in. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 6 Residents are encouraged to maintain their maximum independence with staff assisting them to mobilise where possible and offering them choices over many aspects of their daily lives. Staff members have established a strong rapport with many of the residents through sitting with them and encouraging them to talk about their lives and the history of many of the old family photographs seen in many of the resident bedrooms. 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. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 and 3 Prospective residents and their families are able to make an informed decision based on the information provided about where they wish to live. Arrangements for assessments are in place that ensure all the care needs of the resident are met. EVIDENCE: The Statement of Purpose and service user’s guide was provided to the Commission prior to the inspection. These documents were discussed with the Registered manager and her deputy. Some information needed to be updated to reflect changes made since the home had opened mainly with changes to staffing structures. The home had omitted to include the room sizes of service users accommodation and other facilities provided in the home. The documents were re-formatted by the manager during the inspection and the updated copies were given to the inspector. The home provides all new service users with a brochure that contains a copy of the Statement of Purpose and the residents’ guide together with other information about facilities provided by the home. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 9 Prior to admission to the home a comprehensive assessment of the prospective resident is undertaken. No resident is offered a place in the home until this assessment has been undertaken. Information acquired prior to admission to the home is to ascertain the care needs of the residents. This information is obtained from the resident’s family, medical and nursing staff and others who may have been responsible for the current care of the resident. Following the assessment, the manager will discuss with her deputy and other senior staff in the home the care needs of the prospective resident and whether or not the home can meet the needs of that resident. The needs identified during this assessment form the basis for the plans of care that are written following admission to the home. The home uses a printed format for the assessment, which addresses all the care needs of the resident, both physical and psychological. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10 Improvements and rationalisation of residents’ documentation will ensure that individual care needs will be met consistently. Accurate checking of the medications administered by trained staff will ensure that residents receive the drugs that they are prescribed. The manager and staff members monitor standards in the home ensuring that the privacy and dignity of the residents is upheld at all times EVIDENCE: The inspector examined four examples of residents’ records. To enable the inspector to ascertain that all the necessary information had been obtained with regard to each resident, the inspector had to examine several files each with containing details of the residents. The individual files containing a residents care plans did not have a record of their personal details such as date of admission, next of kin contact details GP and date of birth. All these details were kept in a separate file. The daily records for each resident were documented in another file. The preadmission assessment records were also stored separately. The fragmentation of information made examination of the residents records time consuming. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 11 Examination of the care plans for the residents showed that all individual health care needs had been identified but for some of the residents who had more complex needs, the action plans did not provide sufficient details that would enable staff to address these needs. It was noted in care plans for one resident that information was contradictory and the inspector found it difficult to ascertain exactly how the specific needs were to be met. The inspector spoke to the resident and was assured that his needs were being met. Staff was aware of his needs, but from the care plans, a staff member unfamiliar with the resident, would not be able to address the care needs. The inspector discussed her findings with the manager and her deputy at the time of the inspection. It was agreed that the documentation needed to be reviewed. The home is about to introduce a new computerised care planning format which it is hoped will centralise all the information with regard to each resident and eliminate the storing of information in separate files. Hard copies of care plans will be available for staff to refer to. The inspector emphasised that all care plans must be sufficiently detailed to enable staff to address all the specific health care needs of the residents. The home has policies and procedures for all aspects for the safe administration and storage of medicines. The inspector examined records for the daily medication administration. It was noted that for one resident the record sheet had been signed as the drug having been given but the tablet was still in the packet blister and had therefore not been administered. This was brought to the attention of the deputy manager and a senior nurse who stated that they would investigate this. All other administration records were found to be in order. The inspector spoke with residents and they confirmed that the staff were always respectful towards them and that their privacy was always respected. It was noted by the inspector that Many of the resident chose to have the doors to their rooms open. Staff were seen to knock on all bedroom doors whether opened or closed before entering. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15 The range of activities in the home promotes the residents’ physical and psychological well-being. The arrangements for meals ensures that all residents have a nourishing and well balanced meals and they are offered the choice of where they wish to eat. EVIDENCE: A full-time activities co-ordinator has recently commenced work in the home. She is currently compiling a structured activities programme involving the residents to ensure that the programme is centred on their needs. A formal programme was not in place at the time of the inspection but both the activity co-ordinator and staff members were seen to be interacting with the residents. The home places emphasise on both the physical and pastoral needs of the residents. Daily visits to residents are made by Sisters from the convent which is adjacent to the home. The Sisters assist in the pastoral care for the residents. Residents spoken to appeared to enjoy these visits. Ministers from local churches visit the home and hold regular services. The home has recently installed a video link to the church in the grounds of the convent to enable residents who are unable to attend services to feel they are part of the congregation. This link will also enable the residents to watch other events such as weddings and baptisms. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 13 There are no visiting restrictions to the home and family members are being asked to compile a life history for their relative in the home. Some of the residents attend external organisations and staff are able to take residents to the shops that are very close to the home. Residents spoken to were able to confirm that they have freedom of choice in all aspects of their daily lives. One resident who had recently been admitted to the home said that she was having difficulty in accepting that this was now her home. She said that staff were very kind and thoughtful but that there were times that she wished to be left alone in the privacy of her own room and that the majority of the staff respected this. The home has a very large and pleasant dining room with views to the garden at the rear of the home. Residents are encouraged to come to the dining room for lunch but some choose to remain in their room. Feed back from all the residents with the regard to the meals served in the home was very positive. Menus show that the meals are varied. The inspector was informed that the menus have been complied in consultation with the residents to ensure that their personal preferences have been considered. On the day of the inspection the meal served was well presented and provide a variety of choice. All vegetables are brought to the tables in tureens, which enables the residents to choose the variety, and quantity they wish. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 Complaints are handled objectively and residents are confident that their concerns are listened to and acted upon promptly. Staff are aware of the procedure for the protection of vulnerable adults ensuring that any suspicion of or allegation of abuse is dealt with appropriately EVIDENCE: The home has a robust complaints procedure a copy of which is given to all residents and their families on admission to the home. No complaints have been received by the home at this time so the inspector was unable to examine the complaints records. Residents spoken to all stated that they felt that they would be able to raise any concerns with the staff in the home and that they felt confident that they would be listened to. All staff receive training with regard to awareness for recognising all types of abuse. They confirmed that this training was included in their induction training and that they had read the home’s policies and procedure for reporting any incidences that they became aware of. They were aware of the home’s “whistle blowing” and grievance procedure. The manager explained that staff would have regular awareness training for the recognition of abuse as part of the home’s training programme. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 Arrangements for the cleanliness and general maintenance of the home ensure that the residents live in a clean and safe environment. EVIDENCE: The home has only been open since May 2005. The building has been well designed and provides both communal and private facilities for both staff and residents. All areas throughout the home have been tastefully decorated furnished. Many of the residents have their own possessions in their rooms including pictures and small items of furniture. Landscaped gardens surround the home. Domestic staff are employed and the home was found to be very clean and tidy on the day of the inspection. Staff are employed who are responsible for the maintenance of both the fabric of the building and all mechanised systems in use in the building. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Adherence to the recruitment policies and procedures for the home ensures that staff is employed in such numbers and the skill mix is satisfactory as to meet the needs of the residents. The comprehensive training undergone by the staff ensures that they are competent to provide a high standard of care for all the residents in the home. EVIDENCE: The inspector examined copies of staffing rotas for the home. These showed that sufficient numbers and adequate skill mix of staff were available to meet the care needs of the number of residents in the home on the day of the inspection. The home is recruiting more members of staff to ensure that sufficient staff are available to meet the care needs of new residents as they are admitted to the home. The inspector examined the recruitment records for four staff members. These were found to be in order. Written references had been obtained, application forms, including previous employment history, had been completed and there was evidence of proof of identification. Satisfactory police checks had been undertaken. All the staff in the home has undertaken a very comprehensive induction training programme. This includes: Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 17 Fire safety Safe moving and handling Infection control First aid Food handling and hygiene Recognition and reporting of abuse Staff spoken to stated that the training had been very in depth and they had found the knowledge gained very useful and that having had the opportunity to practice using all the new equipment had added to their confidence when actually using it with the residents. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 Standard 35 was not assessed, as the home does not take responsibility for residents’ money The home actively seeks the opinions of the residents and makes decisions based on this information to ensure that the home is run in their best interests. All safety checks are undertaken on a regular basis to ensure the safety of residents and staff. EVIDENCE: The home has held a meeting with the residents, it was reported that minutes of this meeting were made. The home will be holding these meeting every two months and will also be carrying out surveys to enable residents and their families to put forward any ideas and suggestions. The survey will also provide an opportunity for them to make comments on anything about the home they are not happy about. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 19 Records showed that all safety systems in the home are checked regularly and staff are involved in regular fire safety drills. Prior to the home being opened safety checks were undertaken by the fire safety officer and the environmental health officer. During a tour of the building the inspector noted that all fire exits and doors were free of obstructions. Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 21 N/A 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 7.2 Regulation 15(1) Requirement The registered person must set out in detail a written plan as to how the residents needs in respect of their health and welfare are to be met. A records of all medicines kept in the home for the residents and the date on which they were administered. Staff must ensure that the resident actually receives the prescribed medication. Timescale for action 30-9-05 2. 9.3 17(1)(a) Schedule 3(k) 31-8-05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Marie Louise House 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 20060111 H54 S62154 Marie Louise House V231476 090805 Stage 4.doc Version 1.40 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. 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