Inspection on 09/06/05 for Marillac

This inspection was carried out on 9th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Marillac 12/12/06

Marillac 07/02/06

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 9th June 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Marillac Address Eagle Way Brentwood essex CM13 3BL 01277 220276 01277 221472 info@marillac.co.uk Daughters of Charity 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) CRH 50 Category(ies) of PD Physical Disability (50) registration, with number PD(e) Physical Disability - over 65 (6) of places Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2004 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 I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 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 six 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 acting manager in charge of the day to day management of the home and the deputy director were spoken with. Twenty two National Minimum Standards were inspected on this occasion, sixteen overall outcomes were met and there were five requirements and one recommendation detailed in the full report. Discussion of the inspection findings took place with the acting manager in charge of the day to day management of the home and the deputy director at the end and throughout the inspection, guidance was given. It is acknowledged that the home has had to cope with the sad passing of the previous manager and that the homes present manager is currently off sick until at least September 2005. The inspector was assured that any shortfalls will be addressed and that these are a temporary lapse in the homes current progression. What the service does well: What has improved since the last inspection? What they could do better: The admission procedure must include an adequate assessment which ensures that service users needs can be met. While some improvement has been made to the care planning process some further progress is required to ensure that service users needs are met. The Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 6 health needs of service users are well met although better documentation would ensure clarity of needs. 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 must be well maintained. One aspect of medication administration and recording was not being addressed appropriately. An application for the registration of the manager still needs to be made. Health and safety fire requirements such as drills had not been maintained regularly. 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 I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 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 standard(s) 1,2 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 did not always include an adequate assessment which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: The home has developed a Service User Guide and Statement of Purpose. Service users are encouraged to read the Service User Guide. The most recent inspection report is available for service users. A total of nine service users have been admitted to The Marillac since the previous inspection. Two of these were inspected and it was disappointing to note that detailed assessments of nursing and welfare needs had not been fully completed prior to their admission to the home with the input of the service user where this was possible. There were inadequate records in respect of the assessment of these service users’ care and welfare needs carried out upon the service users admission to the home and the Deputy Director and Acting Manager were advised of these shortfalls on the day of inspection. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6,7,9 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. While some improvement has been made to the care planning process some further progress is required to ensure that service users needs are met. The health needs of service users are well met although better documentation would ensure clarity of needs. Personal support is provided in a way that promotes dignity. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 10 EVIDENCE: Care plans for two newly admitted service users were assessed. These were noted to be incomplete in places, especially in one service users case in respect of how each 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. 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. It was noted that some service users were nursed in bed with bedrails, which did not have protective bumpers. This was also observed at the previous two inspections. It was reported that some service users were incapable of moving in bed and that therefore risks of injury were minimal. While this was accepted staff were advised that the assessment of risks ie entrapment, must include this information in support of the decisions made by staff. 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. 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. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,15,16,17 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. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 12 EVIDENCE: Service users at the home who can access local amenities have access to a wide range of training courses at local colleges and staff encourage service users to pursue courses and activities according to personal choices and capabilities. The home provides suitable transport with specially adapted vehicles. It was reported that service users who cannot access activities in the Community have one to one time with staff including use of the homes sensory room, computer suite and a newly developed sensory garden. The majority of service users living at the home have very complex care needs and cannot access the community. The Deputy Director stated that opportunities have been explored for service users living at the home to attend day centre facilities and at present two service users do. Service users families and friends are welcomed at the home and the input of volunteer groups and individuals is positively encouraged. Daily routines are tailored to the individual needs of service users according to their assessed wishes which are recorded wherever this is practicable. As in the previous three inspections service users spoken with have commented in a very positive manner about the food provided by the home. Records in the form of daily ‘food diaries’ were maintained in respect of the foods eaten by service users living at the home. These included service users comments made in respect of the quality of food provided. Service users who require specialist diets and therapeutic feeding programmes have care plans in place. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 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 standard(s) 18,19,20 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. EVIDENCE: Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 14 As indicated in the previous two inspections the input of specialist support from physiotherapists and occupational therapists was not adequate for the needs of the service users living at the home. On the day of inspection interviews were taking place in order to rectify this situation. Two relatives raised concerns that in particular there was not enough physiotherapy support. At the time of this inspection the home employed one physiotherapist on a part time basis for and three generic assistants who help both the physio and the occupational therapist. There was evidence that pressure sores were being managed satisfactorily although the monthly log had not been completed since April. This was discussed with the manager regarding good practice recommendations. Nursing staff at the home are trained to manage a variety of medical conditions, which reduces the need for hospital admissions, which is very good practice and a medical practitioner reviews Service users on a weekly basis. The majority of service users living at the home cannot manage their own medication. One service user who was capable had a detailed assessment of potential of risks in place, which was reviewed as required. A training update is 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 two of these service users and this was discussed with the units nursing manager. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 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 standard(s) 22,23 The home has an appropriate complaints policy which informs complainants of their rights and assures them their complaint will be taken seriously. Staff are aware of the issues relating to the protection of vulnerable adults. EVIDENCE: The inspector was informed that the homes records in respect of complaints would now include details of the time taken to investigate and respond to the complainant, and the outcomes. It was positive to note at the last inspection that a complaint received by the Commission and referred to the home to investigate under their complaints policy and procedure had been thoroughly investigated and the complainant had been kept involved and informed of actions throughout this process. Most staff working at the home had undertaken training regarding the protection of vulnerable adults and that information had been made available to staff who had yet to undertake this training. Staff spoken with during this inspection could readily demonstrate that they understood what actions to take if there was any incident of witnessed or suspected abuse of service users living at the home. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 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 standard(s) 24,30 The Marillac was clean and bright and airy and provided the service users with homely and comfortable surroundings EVIDENCE: 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. Policies and procedures in respect of the control of the spread of infection were prominent and staff were observed to adhere to these when carrying out their duties. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 Adequate recruitment policies and practices were in place overall. The home has an effective and competent staff team who receive training to the required standard. EVIDENCE: Staff recruitment files for three members of staff were assessed. Some minor shortfalls were noted and bought to the managers attention on the day of inspection but overall it was noted that the home operated a robust procedure and process for the recruitment of staff. Appropriate references, Criminal Records Bureau (CRB) disclosures and proof of individual’s identity were in place. Detailed records were maintained in respect of staff interviews and there was evidence that staff complete a probationary period before a decision is made to offer a permanent position. Staff spoken with confirmed that they received regular mandatory training and there was evidence of the specialist training provided for staff. The homes staff training plan was not assessed during this inspection however this was noted to be satisfactory at the previous inspection. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,42 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 I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 19 The acting manager of the home had sadly and unexpectedly died prior to the homes previous inspection. At the time of this inspection Sr. Margaret Bannerton was overseeing the dayto-day running of the home. It was noted that she, the deputy director and senior staff had worked very effectively in difficult circumstances to ensure the continued smooth running of the home and to support both service users and staff through this very difficult time. At the time of this inspection, Sr. Eleanor Rogers had been post for a short period of time and it was her intention to apply to the Commission to be registered as the homes manager but is currently off sick until at least September 2005, This standard will therefore be assessed in more detail at the next inspection. The Commission receives regular reports in respect of Care Homes Regulation 26. The acting manager had devised a questionnaire to be sent to service users relatives and other stakeholders in order to obtain their views in respect of the quality of the services provided and meetings with service users had been minuted. 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. The five year electrical certificate could not be located on the day of inspection but was later supplied to the inspector. Fire drills had not been regularly documented and undertaken and at the homes previous inspection a fire safety inspection had identified some minor issues. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 4 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Marillac Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 21 YES 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 2 Regulation 14(1) & (2) Requirement New service users must be admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives, (if any), and relevant professionals have been party. (Previous timescale of 30th September 2004 not met.) A detailed service user Plan of Care must be drawn up including consultation with service user, families and significant multidisciplinary personnel and to be reviewed regularly The registered person must ensure that comprehensive risk assessments are carried out for the use of bed rails for all service users where bedrails are used, including details of potential implications of their use for the service users within individualised plans of care. This also with regard to all other risk assessments formulated especially those at risk of falls, pressure sores and smoking and those for COSHH and environmental health and safety Timescale for action 24th August 2005 2. 6 15(1) & (2)17(1)( a) & (b) 24th August 2005 3. 9 13(4) & 13(8) 24th August 2005 Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 22 4. 20 13 (2) 17 (1) 12 (1)–(4) 13 (4) 14 (2) 5. 6. 37 8 (1) & (2)9 (1) & (2) issues (Previous timescale of 30th September 2004 not met.) 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 not met.) The registered person must ensure that the home has a registered Manager. 24th August 2005 24th August 2005 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 42 Good Practice Recommendations The Registered Person shall, after consultation, with the Fire Authority, take adequate precautions against the risk of fires, including the provision of suitable fire equipment, detecting of fires and evacuation procedures. This is as well as ensuring staff are suitably trained and with specific reference to regular fire drills. Marillac I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea SS2 2BG 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 I06 I56 S15544 The Marillac V232484 090605 Stage 4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!