CARE HOMES FOR OLDER PEOPLE
Maris Stella Wing Nazareth House 111 London Road Southend On Sea Essex SS1 1PP Lead Inspector
Mr Trevor Davey Unannounced Inspection 13th January 2006 10:50a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maris Stella Wing DS0000015458.V277301.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 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 Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Maris Stella Wing Address Nazareth House 111 London Road Southend On Sea Essex SS1 1PP 01702 345627 01702 430352 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) The Congregation of the Sisters of Nazareth Mrs Christine McCarthy Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th August 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 Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 13th January 2006 lasting 5.5 hours. The inspection process included discussions with the Facilitation and Care Co-ordination Manager, the Home’s Registered Manager, two staff, six residents and two relatives. A tour of the premises took place and a sample of policies and records were inspected. Fifteen 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. The requirements and recommendations identified in the last inspection report have been implemented including looking at how interests, social and emotional needs of residents can be met and improved on an individual basis. Additional consultation has also taken place to identify residents’ preferences regarding choice and meals selections. Residents spoken to were also complimentary and positive regarding the quality and variety of food provided. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 6 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 Wing DS0000015458.V277301.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 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 the following standard(s): X EVIDENCE: Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 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 the following standard(s): 7, 9 & 10 Although residents health, personal and social care needs are set out in an individual plan of care, consultation had not always taken place with specific health care professionals to ensure individual needs could be safely met and supported by the use of appropriate equipment. Medication procedures were being followed in accordance with the agreed practices. Residents are treated with respect and their right to privacy upheld. EVIDENCE: Personal care records were sampled which included risk assessments for preventing residents injuring themselves and where appropriate, relatives had been involved in the decision-making process. Other health care professionals such as community psychiatric nurses, the psychiatrist and local doctors had been involved where necessary and details of referrals and outcome of reviews were available for inspection. Risk assessments were detailed which included information relating to the options available, effects of taking certain action as well as risk reducing actions. In some cases, additional referrals such as to the occupational therapist, need to be made and risk assessments agreed regarding the safe handling and mobility of residents, together with the appropriate safe use of furniture and equipment. There have been cases where residents have wandered at night and risk assessments must be in place to
Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 10 minimise harm and injury particularly in areas where there are stairways and bathrooms situated. Staff were observed administering the medication and a sample check of the medication administrative records showed that recording had been completed and was up to date in accordance with approved practices. Six staff in the home are involved in medication procedures and specimen signatures were available. Where controlled drugs are administered, these were being stored correctly and recorded in the controlled drugs register along with two staff signatures. Staff have previously attended courses relating to the safe administration of drugs but it is recommended that refresher courses be arranged at appropriate intervals to ensure that latest procedures are being followed. Relatives and residents spoken to confirmed that staff were considerate, caring and upheld the dignity of residents as well as respecting their right to privacy. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12 & 15 Residents are able to enjoy a lifestyle and experiences in the home in accordance with their choice and daily routines. Social stimulation has been improved to give a wider choice of activities to residents and regular consultation takes place regarding choice of meals. EVIDENCE: Since the last inspection, additional social activities such as flower arranging have been introduced which several of the residents enjoy including the opportunity of making table decorations. Video afternoons also take place and one of the relatives stated that her mother enjoys the quizzes and sing-along which take place. The residents enjoy playing board games and cards. The manager stated that questionnaires had been sent out to residents which had been completed (some with the assistance of staff), and the feedback was good including suggestions for changes in the menus. Residents spoken to confirm that there were asked by staff as to their choice of meals and that alternatives were always available. Staff were observed assisting residents with their meals and dinnertime. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 There is an established complaints procedure of which residents are aware. Policies and a whistle blowing procedure are in place for the protection of residents from harm and abuse. EVIDENCE: There were no complaints recorded since the last inspection. A copy of the home’s abuse policy and whistle blowing procedure was available and this had been updated since the last inspection to ensure that clear information was available to staff regarding the correct reporting procedure and agencies to be contacted if such incidents occurred. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 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 the following standard(s): 19 & 26 The home and accommodation is safe, well maintained and clean for the comfort and benefit of residents. EVIDENCE: A maintenance book is maintained which shows a record of items requiring attention, servicing and repair. The record also includes details once these items have received attention. Regular maintenance and safety checks are carried out for the electricity and gas services and the maintenance of the shafts. Portable appliance testing together with fire alarms and smoke detectors had all been serviced during the past twelve months. Staff are aware of infection control procedures and regulations relating to the control of substances hazardous to health. At the time of inspection, the home was clean, pleasant and hygienic. Relatives spoken to confirmed that cleaning of rooms and commodes regularly takes place and this is done to an acceptable standard. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 Residents are supported and protected by the Homes recruitment policy and practices but additional safeguards must also be in place for agency staff who work in the home. Staffing levels need to be reviewed to ensure that residents’ needs can be fully met at all times. EVIDENCE: Staffing levels include the manager, a senior care assistant and five care staff to cover the early and late shifts. In addition, there are two night care staff who are awake and on duty plus a member of the senior staff who is on call and available on the premises. Dependency levels in the home have increased since the last inspection and some of the residents spoken to, stated that there are occasions when two or three staff are required to assist. Additional care hours should be provided for evenings and additional help at mealtimes for residents who require assistance with eating. Staffing levels must also take into account where extra monitoring and support of residents may be required to ensure safe work practices and reducing the risk of falls. Although the agency has supplied a covering letter confirming that all staff supplied to the home have received the necessary recruitment checks, it is regarded as good and safe practice for letters to be issued confirming that these procedures have been followed (including Criminal Record Bureau checks), for each individual member of staff by name. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The Home is responsibly managed to take account of the safety and care needs of residents. The financial interests of residents are properly safeguarded and the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The Registered Manager has been in post for five years and is now registered for the N.V.Q.4 Registered Managers Award. Other courses of training have also been completed. In addition, the Responsible Individual for the two care homes at Nazareth House lives on site and there is also a Facilitation and Care Co-ordination Manager. The financial interests of residents are safeguarded and records of transactions were seen in respect of personal allowances which include receipts and two supporting staff signatures. The Inspector was advised that all residents have a representative or family member to safeguard their interests. The management have procedures in place to ensure that
Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 16 residents and relatives are consulted regarding the daily operation of the home so that individual interests are taken into account. Informal conversations also take place between residents and keyworkers. In addition, Residents meetings are arranged and records were made available for inspection. A new initiative has been launched by the management and letters have been sent out to residents and their families regarding the new building scheme. It is planned that consultation will take place on a regular basis as this project develops. A consultancy letter was made available for inspection (dated May 2005), confirming that the health and safety assessments and inspection which had been carried out, had showed that good progress had been made with risk assessments. There were no major areas of concern. Evidence of maintenance, repairs and servicing carried out to equipment including mechanical lifting equipment, was made available for inspection. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 & 15 Requirement The Registered Person shall make arrangements to provide a safe system for moving & handling of residents by obtaining an assessment, as appropriate, from an occupational therapist which must be included as part of the care plan & risk assessment. The Registered Person shall, having regard to the size of the care home, and the number & needs of residents, ensure that at all times, suitably qualified, competent & experienced persons are working at the care home in such numbers so as to meet the health & welfare of residents. The Registered Person shall not allow a person to work in the care home unless written confirmation is received from the agency concerned, that recruitment checks have been completed (including C.R.B. checks), for the individual persons concerned. Timescale for action 15/02/06 2 OP27 18 28/02/06 3 OP29 19 15/02/06 Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 19 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 OP9 Good Practice Recommendations The Registered Person should arrange for periodic refresher training to be provided to staff who are responsible for the administration of drugs to ensure upto-date practices & procedures are followed. Maris Stella Wing DS0000015458.V277301.R01.S.doc Version 5.1 Page 20 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
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