Inspection on 07/02/06 for Marillac

This inspection was carried out on 7th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marillac 12/12/06

Marillac 09/06/05

Marillac 18/11/04

Marillac 22/06/04

Marillac 03/11/03

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

CARE HOME ADULTS 18-65 Marillac Eagle Way Brentwood Essex CM13 3BL Lead Inspector Helen Laker Unannounced Inspection 7th February 2006 10:00 Marillac DS0000015544.V274765.R01.S.doc Version 5.1 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 Marillac DS0000015544.V274765.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 Adults 18-65. 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. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marillac Address Eagle Way Brentwood Essex CM13 3BL 01277 220276 01277 221472 sreleanor@marillac.co.uk 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) Daughters of Charity Care Home 50 Category(ies) of Physical disability (50), Physical disability over registration, with number 65 years of age (6) of places Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: The Marillac is a care home with Nursing for Younger Adults who have physical disabilities and is registered with Commission for Social Care for the continuing care of 50 men and women with varying degrees of physical disabilities. The Home is located near Thorndon Country Park on the outskirts of Brentwood and is set in four acres of grounds. The M25, the A12 and Brentwood railway station are in close proximity. The building has been extended and adapted to provide three purpose built units, to provide a homely atmosphere for the service users and families. Trained nursing staff and carers are available for the provision of personal and nursing care. Physiotherapists and therapy assistants are also employed to provide therapies and treatments. There is a consultant physician who attends the Home weekly. Parking is available to the front and rear of the building. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over four hours with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. The director in charge of the day to day management of the home and the deputy director were spoken with. Twenty nine National Minimum Standards were inspected on this occasion, twenty five overall outcomes were met and there were four requirements and two recommendations detailed in the full report. Discussion of the inspection findings took place with the director in charge of the day to day management of the home and the deputy director at the end and throughout the inspection and guidance was given. What the service does well: What has improved since the last inspection? What they could do better: One aspect of medication administration and recording was not being addressed appropriately. Robust recruitment procedures must be addressed Supervision on a more regular basis and yearly appraisals for staff must be implemented The registration of the manager still needs to be finalised. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 6 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. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Present and prospective service users and their supporters are given adequate information about the home so that they can make informed choices. The admission procedure includes an adequate assessment which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: Three of the homes most recent admissions, pre admission documentation were inspected. Detailed assessments of nursing and welfare needs had been completed prior to their admission to the home with the input of the service user where this was possible. There were also adequate records in respect of the assessment of these service users’ care and welfare needs carried out upon the service users admission to the home. There was evidence that service users health and welfare needs were reviewed on a regular basis and that other professionals such as physiotherapists, occupational therapists, dieticians etc were involved in reviews and assessments as appropriate. The home also has an in house counselling service. Service users needs and preferences in respect of social, cultural and religious beliefs were recorded and service users are supported in meeting these needs Due to the nature of the healthcare needs of service users at the Marillac unplanned admissions are not usually accepted. Prospective service users and their relatives are actively encouraged to visit the home prior to making the decision to move in. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 9 The home and registered manager develop and agree with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. These were also seen for the homes most recent admissions. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9,10 Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. The care planning process ensures that service users needs are met. The health needs of service users are well met and improved documentation now ensures clarity of needs. Personal support is provided in a way that promotes dignity. EVIDENCE: Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 11 Care plans for three newly admitted service users were assessed. These were noted to be much improved since the last inspection in respect of how each service users nursing, care and social need were to be met including service users perceptions of care needs, preferences in respect of service users capabilities and activities of daily living such as times for getting up and going to bed, method and times for maintaining personal hygiene etc. All care plans which were assessed, were noted overall to be reviewed on a regular basis and according to changes in service users needs. Where changes to treatment or care were necessary this was recorded within the plan and there was evidence that wherever possible service users were involved in planning and reviewing care plans. The home is aiming to ensure all care plans are person centred and reflect the homes essence of care and benchmarking systems. Service users living at the home have very high nursing and physical care needs. As a result the majority of these service users rely on staff working at the home to protect their welfare. Service users who can make decisions are encouraged to do so and are supported according to their needs. Consent issues regarding sensor mats in service users rooms were discussed with the director and deputy director on the day of inspection. There was evidence that service users and their relative or representatives where appropriate were offered opportunities to participate and contribute to the running of the home wherever this was practicable. Service users have the opportunity to attend regular meetings where proposed changes to the running of the home, which would have a direct effect on service users, are discussed. At the previous inspection the deputy director discussed her plan to develop the care plans and risk assessments, as she was aware that the present system could be improved and provide more detail and clearer instructions for staff, this has now been progressed and advice regarding restraint issues at the last inspection acted upon and appropriate documentation implemented There was evidence that service users were encouraged to take responsible risks and detailed assessments of risks including actions to minimise or prevent unnecessary harm to service users were overall generally well maintained. Staff spoken with during this inspection could demonstrate that they understood the homes policy in respect of information given by service users and confidentiality issues. A policy was seen and staff confidentiality agreements discussed. Information kept in the home, which related to service users is maintained securely. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14 Social and educational activities take place and service users are generally happy with the choices in routine available to them. Visitors are made welcome and overall the service users rights and responsibilities are recognised in their daily lives. EVIDENCE: Service users living at the home have opportunities to develop and maintain practical skills, including cooking, numeric and literacy training according to their individual wishes and capabilities. The home has input from an activities co-ordinator four times a week and in addition physiotherapists, occupational therapists, aromatherapists, reflexologists and chiropodists and this is considered to meet the needs of service users living at the home. Service users have access to a wide range of leisure activities at the home including cookery classes, music, bingo and quizzes. Service users who are capable and wish to do so are offered the opportunity to pursue activities outside of the home such as shopping excursions, trips to the pub etc. Service users have access to computer and internet facilities and the home has a very supportive league of friends. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,21 Arrangements are in place to ensure that the health care needs of service users are identified and met. One aspect of medication administration and recording was not being addressed appropriately. The ageing illness and death of a service user is handled with respect, dignity and propriety. EVIDENCE: The majority of service users living at the home cannot manage their own medication. One service user previously who was capable had a detailed assessment of potential of risks in place, which was reviewed as required. Training updates are planned and ongoing for all nursing staff. Medication Administration Records were assessed for three service users. Some omissions of signature on MAR sheets were noted with no indication of any reason for non-administration of medication for one of these service users and this was discussed with the units nursing manager. Staff working at the home receive training in respect of managing illness associated with old age. Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 14 Previously the inspector was informed that two service users families had expressed a wish that the service users were not to receive cardio – pulmonary resuscitation in the event of a cardiac or respiratory arrest. The inspector advised that any decisions regarding this must be supported by the decision of their respective general practitioners. At the time of this inspection a policy in place in respect of resuscitation was not inspected but will be followed up at the next inspection. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not Inspected EVIDENCE: Not inspected Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 The Marillac was clean and bright and airy and provided the service users with homely and comfortable surroundings EVIDENCE: The home is presented in an attractive and comfortable way and adequately meets the current needs of the service users. Since the last inspection the garden has been re-landscaped and double glazing to the whole of the front of the building has been put in. In addition new water tanks have been fitted and the laundry has had a new roof and extractor. The main hall has also been redecorated. All areas of the home were noted to be maintained to a very high standard of cleanliness and hygiene and there were no offensive odours detected during the time of this inspection. Service users living at the Marillac are provided with large spacious, wellequipped single bedrooms with ensuite facilities. Each bedroom has been equipped, furnished and decorated according to the needs and wishes of service users. There are sufficient assisted bathing facilities to meet the needs of service users living at the home. A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 17 The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,36 Adequate recruitment policies and practices were in place overall previously but shortfalls were noted at this inspection. The home has an effective and competent staff team who receive training to the required standard. Supervisions and appraisals were not up to date. EVIDENCE: Records for three members of staff were assessed. These did not all include all documentation as required such as references and CRB checks. Detailed contracts of terms and conditions of employment and clear job descriptions were seen but should be included in all staff’s files. Staff spoken with during this inspection demonstrated that they were fully aware of their roles and responsibilities within the home. Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required time-scales. Staffing levels and staff numbers had been increased on night duty and the director stated that at the present time staffing levels were adequate. Staff spoken to on each unit agreed with this. Staff supervision records, which were assessed, were detailed but were not all up to date. Appraisals at the home have not been done since early 2005 and this must be addressed. In addition staff working at the home must receive regular supervision, which meets the current national minimum standards. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41,42,43 There is guidance and direction to staff and the home has in place practices that will promote and safeguard the health, safety and welfare of the people using the service. Health and safety fire requirements such as drills had not been maintained regularly. EVIDENCE: Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 20 At the time of this inspection the home’s director had returned from sick leave and had been back in post since October 2005 and was managing the day-today running of the home. She is a dual registered general nurse and in learning disabilities. She is also a registered nurse tutor with 40 years experience in the nursing field. An application is currently being processed by the Commission for her to be registered as the homes manager. Regular meetings with service users and staff are held and the minutes of these were available for inspection. Service users, staff and visitors who were spoken with all confirmed that the home was managed in a manner which was open and promoted free exchanges of views, comments and suggestions. The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). Records in respect of the service were noted to be maintained and stored appropriately. Certificates in respect of service and maintenance of gas, electric (including portable appliance testing), lifting and fire safety equipment at the home were noted to be satisfactory at the home’s previous inspection. Fire drills are now being regularly documented and undertaken and attendees names documented. The home has a business plan for the management of the service. This was not assessed at this stage. There was evidence that the business is financially viable. There is a group of financial staff within the organisation and there appeared to be efficient management of the business. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 3 2 3 X 3 3 3 3 Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 22 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 YA20 Regulation Requirement Timescale for action 31/03/06 13(2&4)17(1)12.. 13(2&4)17(1)12(1-4)14(2). The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt of recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. (Previous timescale of 30th September 2004 and 24th August 2005 not met.) 7,9, 19(1)-(7) The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2. YA34 31/03/06 3. YA36 18(1) & (2) 19(1) The registered person must ensure that the employment policies and procedures adopted by the home and it’s induction, DS0000015544.V274765.R01.S.doc 31/03/06 Marillac Version 5.1 Page 23 4. YA37 8(1&2) 9(1&2) training and supervision arrangements are put into practice The registered person must ensure that the home has a registered Manager. It is recognised that an application has been submitted 30/04/06 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 2 Refer to Standard YA8 YA10 Good Practice Recommendations It is recommended that service users consent and or consultation and agreement of relatives is sought for the use of sensor mats or monitoring systems within the home It is recommended that confidentiality agreements are agreed with all staff upon their commencement of employment with the home. Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Marillac DS0000015544.V274765.R01.S.doc Version 5.1 Page 25 - 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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