CARE HOMES FOR OLDER PEOPLE
Maris Stella Nazareth House 111 London Road Southend on Sea Essex SS1 1PP Lead Inspector
Trevor Davey Unannounced 12 August 2005
th 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. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Maris Stella Address Nazareth House 111 London Road Southend on Sea Essex SS1 1PP 01702 345627 01702 430352 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) The Congregation of the Sisters of Nazareth Mrs Christine McCarthy Care Home 36 Category(ies) of OP Old Age (36) registration, with number of places Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Personal care to be provided for up to 36 older people aged 65 years and over. 2. Total number of residents for whom personal care can be provided must not exceed 36. Date of last inspection 16th February 2005 Brief Description of the Service: Maris Stella is registered to provide personal care and accommodation for 36 older people over 65 years of age. It is one of two separately registered care facilities sited at Nazareth house which also has its own chapel, kitchens and laundry. The home is near the town centre at Southend, the railway station, the theatre and all local amenities. The grounds include well maintained gardens and ample car parking facilities. The premises are older in style and retain many of the characteristics which provide challenge and benefits. There is a large main hall which is used for activities and entertainment. The home also has its own beach hut at Shoeburyness that residents can use. Accommodation is sited on three floors and there are two shaft lifts. Most bedrooms are single and a limited number have ensuite facilities. There are three lounges which retain a family home style environment. Additional seating areas are available around the home. Kitchenettes are available on each floor where residents and visitors can make drinks and snacks. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 12th. August 2005 lasting 7.5 hours. The inspection process included discussions with the Responsible Individual on site, the Facilitation and Care Co-ordination Manager, the homes Registered Manager, four staff and five residents. A tour of the premises took place and a sample of policies and records were inspected. Fourteen standards were covered and requirements and recommendations are listed at the end of the report. What the service does well: What has improved since the last inspection?
The management have continued to evaluate care practices and systems within the home and have updated staff training and procedures for the keeping of records and other procedures where required. Improvements have also been made in the storage arrangements of personal-care records to
Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 6 maintain security and confidentiality in accordance with a requirement from the previous 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. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 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 Maris Stella I56-I06 S15458 Maris Stella V243682 120805 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) 3 The service operates a full admission and assessment procedure to ensure that prospective residents are suitably placed in accordance with individual needs to ensure overall care and support can be provided. EVIDENCE: From sample checks made, pre-admission assessments had been completed which identified health and medical details and personal information. Care plan and risk assessments had been completed and updated together with daily and nightly log reports. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 9 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 Residents’ personal health, care and social needs are being properly recorded in individual care plans together with risk assessments where required. Evidence was available to show that health care needs were being fully met by the relevant healthcare professionals. EVIDENCE: Personal care records sampled, showed activities of daily living assessment, which included communication, eating, drinking, as well as sleep and rest patterns. Mobility needs as well as medical details showing involvement of doctors, district nurses and other health care professionals were also recorded. Risk assessments had been updated together with regular evaluations of the care plan. Residents spoken to, confirmed that the quality of care provided by staff was good and that they were very responsive both day and night when the call bell was activated. Residents also confirmed that they were assisted with bathing whilst at the same time, enabled to maintain as much independence as was possible. Positive comments were made regarding members of the staff team who were considerate and responsive to resident’s needs. Some of the residents spoken to confirmed that their care plans and any changes, were discussed with them.
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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 & 15 Evidence was available to show that the lifestyle and experience in the home matches many of the residents’ expectations and preferences. Contact with the community including families and friends is achieved. Religious needs and many of the social interests identified, are met. Whilst residents’ views are sought regarding social activities and choice of meals, improvements need to be found in the way this information is gathered to ensure individual preferences of residents are met to provide greater variety and choice. EVIDENCE: Some of the residents spoken to greatly appreciated the opportunity of attending religious services on site and the spiritual support received. In addition, each resident has an activity sheet included in their care plans showing records of social events attended. A part time social organiser has been appointed and records were available showing how various social activities are co-ordinated and organised. Activities included group singers, musical movement, quizzes as well as visits to the home’s beach hut on the seafront. Records were also available of resident meetings, which had taken place. Care plans sampled, showed social activities identified and how these were to be met. A number of residents have contacts with relatives and friends and are taken out. In some cases, residents are taken out by staff into the local community. Some of the residents have sensual impairments such as hearing problems and felt it was difficult for them to be fully involved in some
Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 11 of the social activities. Although the home has a record of the capabilities and limitations of residents, ways should be found to enable staff to spend time on an individual basis with residents to identify, social and emotional needs which may not necessarily be met on a group basis. Residents spoken to, appreciated when staff were able to spend time talking to them although sometimes they felt staff were busy and there wasnt always the opportunity. Some of the residents spoken to did not feel that food was always properly prepared or they were always consulted about alternative meals which could be provided. A number of menus were inspected and some of the alternatives offered, were not suitably substantial as a main meal. It is suggested that the comments of residents be obtained on an individual basis to clarify their preferences and to ensure that there is a clear understanding that alternatives can be made available. A record should also be kept where residents may be purchasing their own food, the reasons for this and whether this is necessary. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 12 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 & 18 There is an established complaints procedure of which residents are aware. Policies are in place for the protection of residents from abuse, which includes the staff whistle blowing procedure. Details of the local Social Services contact for reporting P.O.V.A. incidents, was not included in the home’s reporting procedures. EVIDENCE: A record of complaints received was made available for inspection where two incidents had occurred and the records showed that all details had been completed together with the action taken and the outcomes of investigations. There was also available a record of compliments and letters of appreciation, which had been received. A copy of the home’s abuse policy and whistle blowing procedure was available and this topic is also covered in the induction and foundation training for staff. Details of the whistle blowing procedure did not include the contact at the local Social Services office where P.O.V.A. incidents have to be reported. Residents spoken to, stated they felt safe in the home and were able to approach staff should they have any matters of concern. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 13 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) 26 From comments received from residents, observation and discussions with staff, effective procedures were in place to maintain a clean, pleasant and hygienic environment. EVIDENCE: Some of the residents spoken to, were very complimentary on the cleanliness and hygiene standards in the home and how their rooms were always kept clean. Staff spoken to, were aware of infection control procedures and the regulations relating to the controls of substances hazardous to health. The laundry and sluice area was inspected which was being maintained to high cleanliness and hygiene standards. All residents spoken to were very appreciative of the standard of washing and ironing of their personal clothing and how this was carried out on a regular basis. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 14 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 & 30 The staffing levels, training and skills were appropriate in meeting the needs of residents at the time of inspection. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staff rotas were available which showed sufficient levels of staff, supervisory and management cover for both day and night. Staff recruitment records were sampled and recent appointments had all necessary documentation relating to application forms, references, identity checks and Criminal Record Bureau searches. Staff are also issued with a handbook and given a copy of the General Social Care Council Code of Practise. The home has a very comprehensive training policy which includes an induction package, with videos, and this is taken over two mornings with new staff. A foundation course is also undertaken within the first six months of employment and staff are issued with workbooks which includes multi choice questions based on the National Minimum Standards for Older People. Feedback is given by management as part of the supervision process. The Facilitation and Care Coordination Manager is a trained trainer and another senior care assistant is also qualified to give moving and handling training to staff. Certificates are issued to staff who successfully complete training. Staff spoken to felt they were well supported, enjoyed the home environment and the personal contact with residents. Staff also confirmed that regular supervision takes place. Good standards of record keeping and documentation were in place for staff employed and their training achievements. Fifty per cent of staff are either trained to N.V.Q. level 2 standard or will be starting their training later this year.
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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) 37 Measures are in place for ensuring the confidentiality and safekeeping of residents’ personal records, policies and procedures. EVIDENCE: Since the last inspection, improvements have been made to the storage and security of residents personal records, which are now kept in the managers office. These records are regularly updated and evaluated, including risk assessments relating to holistic needs of residents. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 16 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2
COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x 3 x Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 17 no 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 18 Regulation 13 (6) Requirement The Registered Person shall make arrangements by training staff or by other measures to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse which must include a whistle blowing policy which gives details for notifying any concerns to the Commission of Social Care Inspection in accordance with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets. The local Social Services Department in whose area the home is situated, must also be notified regarding a prevention of vulnerable adults strategy meeting. In addition, the police must be notified of any abuse of criminal nature. Timescale for action 1/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations
I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 18 Maris Stella 1. 2. 3. 31 12 15 The manager should obtain NVQ level 4 in management and care by 2005. Better arrangements should be made to ascertain interests, social and emotional needs of residents on an individual basis, and to assess how these should be met. A review should take place to see how residents can be better consulted, to ensure the choice, alternatives offered, and standard of meals, meet residents expectations. Maris Stella I56-I06 S15458 Maris Stella V243682 120805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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
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