Inspection on 24/01/06 for Marsh House

This inspection was carried out on 24th January 2006.

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

The inspector 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 18/08/05

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 Inspection 24 January 2006 07:35 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 Marsh House DS0000035535.V275657.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. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marsh House Address Victoria Road Ulverston Cumbria LA12 0ER 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) 01229 894114 01229 894113 david.tyson@cumbriacc.gov.uk www.cumbriacare.org.uk Cumbria Care Mr David Tyson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 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) The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults. 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. Two service users may share a bedroom of at least 16 sqm usable floor 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. 18th August 2005 5. Date of last inspection 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 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. There are also a number of resident’s bedrooms on the ground floor. 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 DS0000035535.V275657.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place at 7.35am to enable me to see the morning routines of the home. I met with many of the residents through the day, either in the living areas or in their own rooms. I formally interviewed four staff and met with the manager and supervisors on duty. I also joined a group of residents for lunch and spent time talking to them in the lounges. I looked at records relating to residents and the smooth running of the home. What the service does well: What has improved since the last inspection? What they could do better: Marsh House is working to a high standard in line with the National Minimum Standards. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marsh House DS0000035535.V275657.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 Marsh House DS0000035535.V275657.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): 1, 3, 4, The home has an effective admission procedure that ensures needs are assessed and can be met in an appropriate manner. EVIDENCE: There have been no significant changes to the statement of purpose and service user guide since the last inspection, apart from updating staffing information. By supplying this information and arranging visits to the home prospective residents have the information to make an informed choice about moving into the home. In addition to a social work or specialist assessment the home complete their own assessment of need. From this they develop a comprehensive care plan. I examined a care plan of a resident who had moved into the home four weeks previously. They had a comprehensive care plan in place to guide and support staff and ensure a continuity of care. This also included detailed risk assessments, which is good practice. These are agreed with and signed by the resident or their representative. Marsh House DS0000035535.V275657.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, 8, 9, 10, 11. Marsh House has good systems for recording and monitoring all personal and healthcare needs. People feel their needs are being responded to appropriately and the staff treat them with respect and their dignity is maintained at all times. EVIDENCE: The home has developed comprehensive care plans for all the permanent residents in addition to people who use the respite and day care services. These are developed with input from all significant parties and based on a detailed assessment of needs. The home also completes a personal profile, which records significant events and personal details from people’s lives. A functional assessment is used to monitor and assess resident’s needs and abilities on a monthly basis, with any changes recorded in the care plan, signed and dated and responded to. There were both manual handling and general risk assessments on file that safeguard residents and promote and maintain their independence. The manual handling risk assessments were particularly detailed and were effective in guiding staff and maintaining theirs and the resident’s safety. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 10 At the end of each shift daily diary notes were completed for each individual with any significant events or changes reported to the supervisor on duty for action. All health interventions were recorded with supervisors maintaining detailed care notes. Key areas such as pressure care and weight are monitored closely and action was taken in a timely manner when changes occurred with the outcome recorded. I examined the contents of the medication cabinet and checked these against the records held in the home. All the records examined were up to date and in order and balanced with the stock control record. Controlled drugs were appropriately stored and administered. Details of resident’s and family wishes upon death are recorded in the care plan. This included information relating to funeral arrangements, finances and any other personal preferences expressed. Marsh House DS0000035535.V275657.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, 13, 14, 15. It was evident the home was providing a good variety of activities and residents were exercising choice and control over their lives. EVIDENCE: Based on my discussions with residents and staff in the three units they enjoy an active social life. People pursue their own interests as well as enjoying group activities and trips with staff support as required. Social needs and interests are recorded in the care plan. Residents talked to me about the recent Christmas festivities, which they had all enjoyed. This included a trip to a local pub for a Christmas meal, Christmas shopping and seeing the Christmas lights in the local town, a special concert with an entertainer and a church service. Resident’s meetings are held on a regular basis, which the home uses to consult with residents about all aspects of home life including activities, menus and special occasions. I looked at the minutes from recent meetings that documented that residents had been “enjoying the activities and trips provided”. The home provides a varied and nutritious menu with meals freshly prepared on site. In addition to the planned choice of meals that residents order the day before, there is always an alternative provided if required. I joined a group of residents for lunch, which was served from a hot trolley at the resident’s Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 12 tables, in the dining area of each unit. The meal was made with fresh ingredients and well presented. All the residents I asked about the food confirmed that they got a “good choice” and that the meals were “always nice”. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 13 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. These standards were assessed and met at the last inspection. The home’s policies, procedures and practice continue to safeguard residents and staff. EVIDENCE: There were no recorded complaints since the last inspection. It was evident from my interviews with four care staff during the inspection they were aware of their responsibilities in identifying and reporting mistreatment and abuse. Training for staff was provided using a training video with a question sheet to test their knowledge and understanding. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 14 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, 20, 21, 22, 23, 24, 25, 26. Marsh House provides a safe and comfortable living environment that is well maintained. The equipment and facilities ensure individual needs can be met. EVIDENCE: The home has an ongoing programme of repairs and renewal that maintains a safe and comfortable environment. The carpet in the Victoria unit lounge is showing signs of wear on the joints. However this has been noted by the manager and is to be replaced in this financial year. Three bedrooms have also been identified for decoration in the same period. All the bathing and toilet facilities were accessible with suitable aids and adaptations in place. This included an accessible shower and bath hoists. These had been recently serviced as required. There was evidence of other aids and adaptations around the home to support and promote residents independence such as standing frames, walking frames and hoists. Referrals are made to other specialist services for assessment with their recommendations implemented. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 15 During my discussions with residents they explained how they had brought their own furniture and belongings into the home. This was something they valued and was important to them in making the place more homely. Two residents had purchased their own automated recliner chairs, which was also beneficial in helping them stand up from the chair. The units provide a comfortable living space with suitable furniture and a pleasant kitchen/dining area. All areas of the home were found to be clean and hygienic. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 16 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, 28, 29, 30. The home has sound recruitment procedures and currently has a full compliment of well-trained and committed staff. EVIDENCE: The home has been allocated additional care staff hours to appoint a member of staff to support the supervisor, taking on a “quality checker role” with administration of medication. The staffing hours in the home were adequate to meet the needs of the current group of residents. Staff spoken to said their experience of the recruitment process was “positive” and they got “good training and support”. All necessary checks were completed and I examined an up to date list of staff CRB disclosures, these were all in place and up to date. Regular bi-monthly staff meetings are held with an open agenda being displayed in the staff room, enabling staff to identify any agenda items of their choosing. The manager provides regular feedback and briefings to staff in relation to organisational issues as well as agenda items more pertinent to the running of the home. Staff said the meetings were “really useful” and “kept them up to date”. The home provides a staff room with individual lockers, with relevant information displayed on the notice board. Six staff recently completed their NVQs of which they were quite rightly proud and were looking forward to a presentation day when their hard work would be acknowledged. There is currently another nine staff working towards the award. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 17 All staff had been issued with a continuous professional development file to record and monitor all training and development activity. The files I sampled were up to date and reflected an appropriate level of training taking place. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 18 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): 32, 33, 36, 37, 38. The home benefits from having a stable management and staff team. They are very committed and supportive of each other, in working towards a common goal, of ensuring a consistent and reliable service. EVIDENCE: The manager produces a quarterly report, which was displayed on the staff notice board. This is used to monitor and report on key areas relating to the effective and efficient running of the home. The home identifies targets within their business plan, which is in line with the organisations business plan. Staff said they “received regular supervision and got good support” from the manager and supervisory team, “we can approach them with anything and we don’t have to wait for supervision to discuss it”. Annual appraisals are also completed that identify personal development targets for staff. The home consults with residents on an ongoing basis with “link workers” taking a lead role in liaising with residents and their representatives. As Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 19 mentioned previously regular residents meetings take place and a formal consultation is completed on an annual basis. Records relating to the running of the home and health and safety were examined and found to be up to date and accurate. The kitchen is well equipped with sound monitoring systems in place regarding food storage and cooking temperatures. The cleaning routines maintain a clean and hygienic environment throughout the home. A recent review of manual handling procedures and practice was very positive. Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 20 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 3 X 3 3 X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 X 3 3 X X 3 3 3 Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 21 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. 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. Refer to Standard Good Practice Recommendations Marsh House DS0000035535.V275657.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria 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. 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