Inspection on 19/09/05 for Marshview

This inspection was carried out on 19th September 2005.

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

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

Other inspections for this house

Marshview 06/06/07

Marshview 16/05/06

Marshview 22/04/05

Marshview 30/09/04

Marshview 20/04/04

Similar services:

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

The Shelley

Springfield House

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

CARE HOMES FOR OLDER PEOPLE Marshview 77 Marshfoot Lane Hailsham East Sussex BN27 2RB Lead Inspector Gwyneth Bryant Unannounced Inspection 19th September 2005 11:25 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 Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marshview Address 77 Marshfoot Lane Hailsham East Sussex BN27 2RB 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) 01323 849207 01323 849207 Mrs Maria Mapletoft Mrs Maria Mapletoft Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is seventeen (17). Service users accommodated must be older people aged sixty-five (65) years or over on admission. 22nd April 2005 Date of last inspection Brief Description of the Service: Marshview is a large detached two-storey house situated in the market town of Hailsham. It is registered to provide care and accommodation for up to 17 older people. There are three double rooms, of which one has en-suite facilities and eleven single rooms. Nursing care is not provided. The home is situated in a country lane that is within walking distance of local shops and amenities. There are well maintained rear gardens and car parking facilities at the front of the property. All parts of the home are accessible via a stair lift and portable ramps give access to the front of the home and the rear gardens. Grab rails and toilet riser seats are installed throughout the home. There are three assisted baths and all bedrooms have a hand washbasin. None of the rooms have full en-suite facilities but there are sufficient toilet and bathing facilities to meet service users needs. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and there were fifteen residents in residence on the day. The inspection was undertaken over four and a half hours and its purpose was to check that the requirements of previous inspections had been met. Thirteen key standards and two of the remaining standards were inspected. A number of records and documents were viewed; including the complaints book, medication records and care plans. A tour of the premises was carried out. Six residents, the Manager and one carer were spoken with. What the service does well: What has improved since the last inspection? What they could do better: Pre-admission and care planning documents need to be complete and include all the required information in order to guide staff in all aspects of residents care and demonstrate the home can meet assessed needs. Detailed risk assessments need to be carried out to enable residents to safely undertake risks in their daily lives. All complaints need to be recorded as part of the quality assurance system. Recruitment practices needs to ensure that all staff provide an employment history and two references prior to appointment to protect residents. Residents would benefit from an appropriately supported staff team. Staffing levels need to be increased to enable the Manager to fulfil her management duties. Systems need to be developed and implemented to ensure residents are regularly consulted in how their care is delivered and how the home is run. Appropriate lifting equipment needs to be provided to enable staff to safely lift residents from the floor. The requirements relating to health and safety need to be addressed to ensure residents health and welfare is protected. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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 Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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, 2, 3 and 4. Standard 6 is not applicable. Prospective residents would benefit from more detailed information about services provided by the home. Systems for assessing residents needs are inadequate and do not ensure their needs can be met. EVIDENCE: The home has reviewed its Statement of Purpose and this document now includes all the information as required under Schedule 1 of the Regulations. However, practices do not adhere to the guidance as laid down in this document. The home has reviewed the Service Users Guide but the Registered Provider was unable to provide a copy of the document on the day of the inspection. Two pre-admission sheets were viewed and it was found that they had not been completed and do not include all the information as required by the Standard therefore there was no evidence the home could demonstrate it could meet service users needs. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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 and 9 Residents would benefit for a more comprehensive care planning system that guides staff in all aspects of personal and health care and that all risks are identified and planned for. Residents are protected by satisfactory systems for the recording, handling and storing of medication. EVIDENCE: Five care plans were viewed and it was evident that some needs had been identified and planned for. However, most plans were incomplete, not regularly reviewed and there was no evidence to show that residents or their representatives are involved in compiling and reviewing the plans. Care plans need to be formulated from the pre-admission document to ensure care provision is tracked from the time of admission. Care staff and the Manager spoken with were aware of residents individual care needs but this system relies on good verbal communication and good staff memory. Residents are at risk if these informal systems breakdown. Residents spoken with said they believed staff were aware of their care needs and felt that they are properly looked after. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 10 Basic risk assessments had been carried out but they do not clearly identify the hazards nor include sufficient detail for the management of risks, this is especially true for those who smoke, are at risk of falls or tissue breakdown, drink alcohol or have particular disabilities. There was little evidence to show that service users are given the opportunity to self-medicate and this needs to be addressed. Clear procedures for managing incontinence need to be developed and implemented. Some residents plans showed they need therapeutic exercise to recover their mobility but there was no information detailing how often it needs to be performed nor which staff are responsible for ensuring they are carried out. The Medication Administration Record (MAR) chart was viewed and found to be satisfactory. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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 and 15 Residents would benefit from a daily programme of activities based on their preferences. Visitors are welcome to the home at all reasonable times to ensure residents maintain links with family and friends. Residents are encouraged to exercise choice over their daily lives. Meals are creative and nutritious offering both choice and variety EVIDENCE: Some activities are provided and care staff spoken with mentioned games they had provided for residents. However, a planned programme of activities based on resident’s preferences needs to be created and implemented. This would ensure residents are given the opportunity to continue with current and past hobbies and pastimes. Residents social and leisure interests need to be recorded in both pre-admission documents and in care plans. On the day of the inspection some residents remained in their rooms while others sat in the lounge listening to music. Residents told the inspector that there was often not much to do although all said that care staff try to spend time chatting or providing activities. All residents spoken with said that the food was good and that they are given a choice of meals. They also said that they are encouraged to eat in the dining room but may take meals in their rooms if they wish. Menus showed that Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 12 balanced and varied meals are offered. Records are held detailing daily food choices for each resident. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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 Satisfactory systems are in place to deal with complaints but not all complaints are recorded therefore quality assurance is compromised. EVIDENCE: The complaints book was viewed and it was clear that most complaints are recorded and include outcomes. However, a resident raised an issue during a residents meeting and this was not recorded even though the resident felt a member of staff had not treated him appropriately. This was discussed with the Manager who stated she had spoken to the member of staff involved and the resident was satisfied with the outcome. This needs to be addressed as recording of all complaints enable the to Registered Provider to review shortfalls in the service and address them. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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, 22 and 24 The standard of the environment within this home is good providing residents with an attractive and homely place in which to live. Improvements need to be made in respect of replacing or renovation of commodes that are rusty to reduce the risk of infection. Locks on communal bathrooms and toilets need to be of a type that enables staff to enter in an emergency. Resident’s bedrooms are comfortable and they are able to bring in their own possessions. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is good throughout. Marshview provides comfortable and homely communal space, consisting of a lounge and adjoining dining room. Residents are encouraged to personalise their own rooms and many have done so with ornaments, pictures and small pieces of furniture. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 15 A number of commode frames were noted to be rusty and these need to be renovated or replaced as this is a source of infection as rusty parts cannot be easily cleaned. Locks on communal bathrooms and toilets doors need to be of a type that enables staff to enter in an emergency. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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 and 29 The deployment and number of staff at key times is insufficient to meet service users care needs. The recruitment practice is not robust and does not provide sufficient safeguards for the protection of service users. EVIDENCE: Staff rotas were viewed and a total of 276 care hours are provided. One night waking staff is also employed. The home also employs cooks and domestic staff in addition to a gardener. The Residential Forum staffing tool recommends a minimum of 352.17 care hours based on current residents dependency levels and taking into consideration the layout of the home. Discussion with the Manager established that she provides cover for staff sickness and holidays and this impinges on her management time. This needs to be addressed to ensure she has sufficient time to undertake all management tasks. Residents told the inspector that when staff are busy call bells are not answered promptly. One resident had not received her after lunch coffee until 3pm and this was because staff were very busy and forgot to bring it to her. Recruitment records were viewed and it was found that not all staff provided two references and an employment history. Staff had been employed who do not have the training and experience relevant to caring for older people. These issues must be addressed without delay to ensure residents are protected. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 17 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, 32, 33, 36 and 38 Residents would benefit from a review of the Managers management hours to enable her to run the home efficiently and effectively, including providing support to staff. The ethos of the home is open and some improvements to staff and resident’s consultation have been made. All aspects of residents health, safety and welfare need to be protected and promoted. EVIDENCE: The Registered Manager is suitably qualified and experienced to run the home. However, she frequently provides cover for staff sickness and holidays. As a result she does not have time to support and supervise staff and ensure the home is properly managed. One residents meeting has been carried out since the last inspection and minutes were available for inspection. It was evident that this meeting encouraged residents to raise concerns and make suggestions in respect of menus and activities. Such meetings should be held more frequently to give residents further opportunity to comment on all aspects of the service. Staff Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 18 meetings need to be undertaken monthly to ensure staff also have the opportunity to have a say in how the home is run. The introduction of formal quality assurance and quality monitoring systems would enable the provider to critically evaluate the service and ensure it is run in residents best interests. Formal staff supervision is not provided in accordance with the regulations and this is because the Manager does not have sufficient time to provide this oneto-one support to staff. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. Suitable equipment to enable residents to be safely lifted from the floor needs to be purchased as there is only one member of staff on duty at night. Weekly testing of the call bell system and water delivery temperatures need to be undertaken and recorded to ensure residents health and safety are protected. Locks fitted to communal bathrooms and toilet facilities need to be of a type than enables staff to enter in an emergency. Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 19 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 2 2 2 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 X 3 X X 2 X 3 X X STAFFING Standard No Score 27 2 28 X 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 1 X 3 2 X 2 Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 2 Regulation 5 (1) (b) Requirement Timescale for action 19/12/05 2 3 3 4 4 7 5 7 Service users contract and terms and conditions need to incude all the information listed under the standard. (timescale of 22.07.05 not met). 14(1abc) Pre-admission documents must (2ab) contain all aspects as listed under the standard. (timescale of 22.07.05 not met). 12(1ab)14 The home needs to demonstrate (1d) that it can meet service users assessed needs. (timescale of 22.07.05 not met). 13(4bc) Service users care plans need to 15(2bc) be regularly reviewed and accurately reflect service users current needs. Service users or their representatives need to be involved in compiling and reviewing of care plans. Care plans need to be consistent and inlcude all care needs. (timescale of 30.12.04 not met). 13(4b)11 Risk assessments must be 2(1ab)(2) undertaken for those service users at risk of falls, who drink alcohol or have particular disabilities. Assessments must include the management of DS0000021161.V250935.R01.S.doc 19/12/05 19/12/05 19/12/05 19/12/05 Marshview Version 5.0 Page 21 6 7 7 8 8 8 9 9 10 12 11 16 12 13 14 22 27 29 15 16 17 32 32 33 identified risks. (timescale of 22.07.05 not met) 15 (1) Service users care plans must include all the information as listed under Schedule 3 of the Regulations. (timescale of 22.07.05 not met). 12(1)13 Evidence of the management of (1)17(1a) incontinence and for those at risk of tissue breakdown needs to be provided as under schedule 3 (p). 12(1ab)13 That action is taken when service (1b) users are noted to have lost weight or have a particular health problem as under Reg 17 (1) (a) & Schedule 3 (o) (timescale of 22.07.05 not met 12(2)(3) That service users be given the (4a) opportunity to self medicate within a risk assessed framework as under 13 (4) (a-c) . (timescale of 22.07.05 not met) 16(2)(m) That a daily programme of (n) suitable in-house activities based on resident’s preferences be created and implemented. 22 (3-6) That all complaints and concerns are recorded and include actions taken and outcomes as under Reg. 17 (2) schedule 4 (11) 13(4c) That rusty commodes are 16(2c) renovated or replaced. 18 (1) (a) Staffing levels need to be increased to ensure service users needs are met. 19(1abc) All staff need to provide the (2)(3)(4) required documentation listed in Schedule 2 of the Regulations prior to appointment. 24(1ab) That residents meetings be 12(2)(3) carried out monthly. 12 (5) That staff meetings be carried (ab) out monthly and the minutes made available for inspection 24 (1)(ab) That formal quality monitoring (2)(3) and quality assurance systems DS0000021161.V250935.R01.S.doc 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 19/12/05 Marshview Version 5.0 Page 22 18 19 36 38 20 38 21 38 be created and implemented. That all care staff receive formal 18(1)(2) supervision at least six times a 19(1)(a-c) year. 13 (4) (a- Locks fitted to communal c) bathrooms and toilet facilities need to be of a type that enables staff to enter in an emergency. 13(5)(a-c) That equipment be provided to 16(2)(c) enable staff to safely lift service users from the floor as under 23(2)(n). 13 (4) That call bells and water delivery (abc) temperatures be tested regularly. 19/12/05 19/12/05 19/12/05 19/12/05 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 Marshview DS0000021161.V250935.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Marshview DS0000021161.V250935.R01.S.doc Version 5.0 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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