Inspection on 18/08/05 for Marsh House

This inspection was carried out on 18th August 2005.

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

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

Other inspections for this house

Marsh House 24/04/07

Marsh House 24/01/06

Marsh House 28/02/05

Marsh House 24/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Marsh House Victoria Road Ulverston Cumbria LA12 0ER Lead Inspector Ray Mowat Unannounced 18 August 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 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. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Marsh House Address Victoria Road Ulverston Cumbria LA12 0ER 01229 894114 01229 894112 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) Cumbria Care David Tyson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number of places Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. The home is registered for a maximum of 30 service users to include: - up to 30 service users in the category of OP (Old age not falling within any other category) 3. The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults. 4. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 5. Two service users may share a bedroom of at least 16 sqm usable flloor space only if they have made a positive choice to do so, and when one of the shared spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary. Date of last inspection 25 February 2005 Brief Description of the Service: Marsh House is a care home registered to provide residential accommodation for 30 people over 65 years of age. It is situated in a residential area of the town of Ulverston, Cumbria, within walking distance of the amenities of the town centre. The home is on two floors, the top floor being accessed by one of two passenger lifts or staircases. The ground floor has nine bedrooms on the ground floor and is divided into three distinct living areas: Richmond, Springfield and Victoria that each comprises a lounge and kitchen/dining area. Residents move freely between the three living areas. The remainder of the bedrooms are on the first floor in addition to communal bathing and toilet facilities. The home has a well kept garden and off road parking facilities to the front and a private, enclosed garden and patio area to the rear. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 18th August 05. The inspector met with many of the residents during the day, including the “case tracking” of three residents. This involves meeting the resident and the staff that support them and then examining their care plan files. There was a good response from resident’s comment cards and relative’s and visitors comment cards, which reflected an overall satisfaction with the service provided. During the course of the inspection, the inspector also spoke to families who were visiting the home and a visiting District nurse. The inspector spent time in all areas of the home talking to residents and staff, joining in a group activity, in addition to formally interviewing four staff, which included two senior staff and two care staff. What the service does well: What has improved since the last inspection? What they could do better: Although it was evident the home is providing a good range of activities, based on the results of the residents survey this area did not score well. Assessments completed by the home identified people’s interests and hobbies, however this information was not transferred into the care plan, which could result in information being lost and needs and preferences not acknowledged. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 6 It is recommended the inclusion of “interests and hobbies” and how they will be supported by the home, should be recorded on the care plan. 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. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 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 Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 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) The home’s admission policies, procedures and practice, ensure prospective residents are fully informed and their needs assessed, prior to choosing to live in the home. EVIDENCE: The home has produced an informative statement of purpose and service user guide, which was offered to all prospective residents. This ensures they have all relevant information to make an informed choice about moving into the home. There was evidence these have been reviewed and updated as required. Contracts of terms and conditions were held on personal files, which had been agreed and signed by residents or their representatives. The home provides both day care and respite care services. This gives people an opportunity to “test drive” the home and in some cases has lead to people choosing to live in the home on a permanent basis. The majority of admissions to the home are planned, with people given the opportunity to visit the home for a meal or overnight stay, prior to making a decision about moving in. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 9 The home will also take emergency admissions on the understanding that they are provided with an assessment and that the placement is short term, to enable full assessments to be completed. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11. Individual health and personal care needs were well documented, ensuring a consistent and responsive service is provided. EVIDENCE: Prior to and soon after admission the home will complete an assessment of need and personal profile. These identify individual needs and preferences and enable the home to develop detailed care plans. These have recently been reviewed and more comprehensive information included. However, although interests and hobbies were recorded on the assessments, these have not been included within the care plan. It is recommended individual preferences in relation to social interests and hobbies, be recorded in the care plan, with guidance for staff on how they can support people in pursuing their interests and hobbies in a safe manner. There was evidence care plan files were being agreed with residents or their representatives and regularly reviewed, including the completion of a functional assessment on a monthly basis. The home supports people to access relevant health care services, with all residents being registered with a GP of their choice. Supervisors maintain a record of all health related interventions and appointments ensuring pertinent information is transferred onto care plan files and shared with relevant staff. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 11 Records were sampled and found to be up to date and accurate. The inspector also met with a visiting District nurse, who confirmed that the home make appropriate referrals and work closely with the community health team to meet individuals healthcare needs. The inspector sampled medication records (MAR charts) against medication held, also including controlled drugs and stock records, these were found to be in order. The home’s new policy for administration requires a second member of staff to witness and sign that the procedure has been completed satisfactorily. This can be problematical if there is a staff shortage in the home. Individual’s wishes upon death and their spiritual needs are recorded within personal files. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15. It was evident people were supported and encouraged to lead a fulfilling lifestyle of their choice, with staff respecting individual needs and preferences. EVIDENCE: It was evident from discussions with residents and staff and examination of records that the home was working proactively with residents, staff and volunteers to provide a varied range of activities. However the subject of activities did not score very highly in the last residents survey. The inclusion of interests and hobbies within the care plan, referred to previously, should ensure people are aware their preferences and wishes are noted and responded to appropriately. On the day of the inspection two volunteers facilitated a craft group during the afternoon, which were producing various goods for sale at the home’s forthcoming summer fair. This session took place in one of the three lounges, enabling people to pursue alternative interests, if they did not wish to join the group. The residents spoken to were enjoying the social aspect of the occasion as well as the personal satisfaction of producing the goods. Daily activities were posted on the home’s notice board, which tended to take place each afternoon on a group basis. The staff at the home organise a weekly bonus ball draw, which helps to raise funds for a weekly bus trip or other social activities, such as Tai Chi exercise classes. Other popular activities Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 13 residents spoke about included a film afternoon, sing-along and musical entertainment by a local duo. The home also has links with the local churches with a regular service held in the home. Another facility provided by volunteers is a weekly trolley shop that gives residents an opportunity to buy sweets and personal sundries. The inspector joined a group of residents for lunch, which was served in one of the dining areas from a hot trolley. This was freshly prepared and well presented. Residents confirmed that the meals were good quality with plenty of choice and special diets catered for. One person described them, as ”lovely and there is always plenty”. The menus examined also confirmed a varied and nutritious selection of meals. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18. Resident’s rights are protected by the home’s policies and practice, with management providing support and guidance for residents and staff. EVIDENCE: The home issues a detailed complaints policy and procedure, which is also displayed in the home that meets the requirements of the care home regulations. Residents and visitors spoken to were aware of how to complain. Staff were also familiar with the policy and reporting procedures. There had been no recorded complaints since the last inspection. Staff felt this was the case, as when concerns were raised with them, they were responded to and resolved immediately and did not become a formal complaint. The home manages small amounts of personal finances with clear records maintained of all transactions, with two staff signing both deposits and withdrawals. These were sampled by the inspector and found to be in order. Based on discussions with staff they were aware of the policies of the home and their responsibilities in identifying and reporting abuse. Staff had completed appropriate training, which was being periodically refreshed using a video training package and worksheets. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Marsh House is safe and well maintained and provides a comfortable living environment that meets the needs of the current residents. EVIDENCE: In liaison with the organisations accommodation manager the home has produced a condition survey to prioritise planned repairs and renewals. During a tour of the building two rooms were identified as requiring re-decoration, these were reflected in the plan. In addition the carpet in Victoria lounge was also in need of replacement, which had also been prioritised. Although some of the decoration was dated, the home was in a clean and serviceable condition. There is ample communal space in the home to meet the needs of the current residents. The three lounges are adjacent to each other, which creates a homely atmosphere in each one, with residents also able to move freely between them to socialise. One resident is a keen gardener who, with the support of a member of staff, is tending the flower tubs and borders. These were really colourful and brought a lot of pleasure to residents, who enjoy sitting in or overlook the garden. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 16 Many residents have brought their own furniture into the home and personalised their rooms with pictures and other personal belongings. Suitable aids and adaptations were in place around the home, with evidence of the home liaising with relevant professionals for specialist advice or guidance. On the day of the inspection there were no obvious hazards noted. The home has dedicated domestic staff who maintain a clean and hygienic environment. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 17 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, 28, 29, 30. Marsh House has an experienced and well trained supervisory and staff team, who are able to meet the needs of residents and ensure their safety at all times. EVIDENCE: Through examination of staff rotas and the inspector’s own observations there were sufficient numbers of staff on duty in the home. On each shift the supervisors take a lead role and can provide support and guidance to staff in all areas of the home. In addition to the permanent staff the home has a work place student who is working toward their NVQ qualification. They are supernumery to the core staffing in the home. The home also has a number of volunteers who provide group activities in the home alongside regular staff. All staff and volunteers had gone through appropriate recruitment procedures and employment checks ensuring residents were safeguarded. With assistance from peripatetic NVQ assessors employed by the organisation, staff have been achieving their NVQ qualifications in a timely manner. Based on the current staff group who are registered for NVQ or have completed the award the home will have 50 of staff trained by the end of 2005. The manager has comprehensive monitoring records training completed and refresher or core training required. This enables the manager to track all training activity ensuring training requirements are achieved in line with the National Minimum Standards. The inspector formally interviewed four staff who were suitably trained and experienced. The organisation has recently introduced Continuous Professional Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 18 Development files for each member of staff to ensure all pertinent training and development information is appropriately recorded. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 38. The manager and supervisory team provide clear leadership and effective supervision and support, ensuring the safety and best interests of residents are safeguarded. EVIDENCE: Based on the inspector’s observations and discussions with residents and staff, the manager provides good leadership and working closely with the supervisory team, ensures a consistent level of care is maintained. He has suitable qualifications and has considerable experience in the care of older people. One of the four supervisors takes a lead role on each shift, staff felt they received “good supervision and support on a day to day basis and through formal supervision every six to eight weeks. Supervision records were examined, which were up to date and contained relevant recordings. The manager keeps a matrix to monitor supervisions, fire training and reviews, Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 20 ensuring they are taking place in the required timescales, which is good practice. Residents meetings are held every three months and are recorded, in addition staff meetings are held every two months, with an open agenda, ensuring suitable issues relating to life in the home are discussed. The home also consults formally with residents on an annual basis using a resident’s survey. The results of the survey are collated and feedback is given to residents at a meeting, when an action plan is agreed. Health and safety checks and routine servicing and maintenance records were examined. These were found to be up to date and accurate ensuring a safe environment was maintained. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 x 3 Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 22 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 Regulation Requirement Timescale for action 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 7 Good Practice Recommendations It is recommended peoples preferences regarding their interest and hobbies are recorded in the care plan, with guidance for staff on how to support people to pursue their interests. Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith CA11 9BP 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 Marsh House F58 F10 s35535 Marsh House v188373 UI 180805 Stage 4.doc Version 1.40 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. 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