Inspection on 22/04/05 for Marshview

This inspection was carried out on 22nd April 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 19/09/05

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 22 April 2005 07:50 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. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Marshview Address 77 Marshview Lane Hailsham East Sussex BN27 2RB 01323 849207 01323 849207 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) Mrs Maria Mapletoft Mrs Maria Mapletoft Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (OP) 17 of places Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number to be accommodated must not exceed seventeen (17). 2. Service users must be older people aged sixty-five (65) years or over on admission. Date of last inspection 30 September 2004 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 H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over three and a half hours. There were fifteen service users in residence on the day of which eight were spoken with. The purpose of the inspection was to check compliance with the requirements from the last inspection and inspect additional standards. One member of staff, two relatives and the Registered Manager were spoken with. Documentation was viewed including personnel files, medication records and care plans. A tour of the premises was carried out. Nine key standards and ten of the remaining standards were inspected. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users Guide need to be reviewed to reflect changes and enable service users to make an informed choice. Risks assessments need to be produced that clearly identify hazards to service users and the management of the risk, including that related to self-medication. Recruitment documents need to be held on the premises and available for inspection. All medication administered needs to be recorded and administered at the prescribed times. Pre-admission documentation needs to include all the aspects as listed under the standard and care plans also need to be expanded. Systems need to be developed and implemented to ensure service users are 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 service users. Regular fire drills need to be undertaken. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 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 Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 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) 1, 2, 3 and 4 Prospective service users are not provided with sufficient information about services provided by the home. Systems for assessing service users needs are inadequate. EVIDENCE: The homes Statement of Purpose and Service Users Guide were viewed and it was found that they had not been reviewed to reflect changes in the service. Service users contracts include their terms and conditions. These documents do not include all the information as required under the standard. Three preadmission sheets were viewed and it was found that they had not been completed therefore there was no evidence the home could not demonstrate it could meet service users needs. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 Limited progress has been made in improving the care planning system to provide staff with the information they need to satisfactorily meet service users needs. Service users healthcare needs are not fully met. Systems for administering and recording medication are inadequate. EVIDENCE: Service users care plans were viewed and it was found that they are not consistent and do not include all aspects of care needs. Risk assessments are inadequate and do not clearly identify the risk nor outline how the risk is to be managed. This is particularly true for the one service user who has sight impairment and for the service user whose confusion has increased significantly. There was no evidence to demonstrate service users or their representatives had been involved in the care planning process. Where service users are noted to have lost weight or have dietary issues, no evidence was available to demonstrate that healthcare professionals had been consulted. The Medication Administration Record (MAR) chart was viewed and not all administered medication had been recorded. The 8 am medication was not administered until 8.45 when the Inspector raised the delay with the Manager. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 10 There was little evidence to show that service users are given the opportunity to self-medicate and this needs to be addressed. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 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 standard(s) 15 Meals in the home are good offering both choice and variety. EVIDENCE: Six service users spoken with all said that the food was excellent 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 balanced and varied meals are offered. The Manager said she tries to include service users favourite meals in the home’s menus. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The home has systems in place to ensure service users are protected from abuse. EVIDENCE: The home has detailed policies and procedures on adult protection that include a whistle blowing procedure. All staff have recently completed training in adult protection and the certificates of attendance were available for inspection. Discussion with the Manager found that she is knowledgeable about adult protection procedures including the requirements of POVA. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25 and 26 Service users benefit from a clean, comfortable and well-maintained home. EVIDENCE: Guards have been fitted to radiators and restrictors fitted to all windows that require them. Pre-set valves have been fitted to hot water outlets to which service users have access ensure hot water is delivered at a safe temperature. The laundry was clean, with washing machines that wash soiled laundry at high temperatures. A tour of the premises found that all parts of the home are clean, tidy and hygienic and free from offensive odours. The Manager and staff have been trained in infection control and certificates of attendance were viewed. The Manager is aware of good practice in respect of infection control. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 Staff have the skills and training to perform their roles effectively. EVIDENCE: Documentation showed that five members of staff have achieved NVQ Level 2 in care and two others are working towards gaining this qualification. Documents demonstrating that staff undertake induction and foundation training in line with the National Training Organisation specifications were viewed and found to be satisfactory. Three service users spoken with said that staff were well trained and delivered care with consideration and respect. It was noted that the cleaner maintains a good rapport with at least two service users and takes the time to chat to them while cleaning their rooms. The home has policies and procedures on recruitment however, records in respect of the homes latest staff recruitments were not available for inspection and therefore this standard could not be fully assessed. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 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 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, 35, 36 and 38 The Manager has an understanding of where improvements need to be made within the home. There are no formal systems in place for service user consultation with little evidence that service users views are sought and acted upon. There are systems in place to safeguard service users financial interests. Service users benefit from a supported and appropriately supervised staff team. Arrangements are in place to ensure the welfare and safety of service users, which would benefit from the provision of appropriate lifting equipment and training for staff. EVIDENCE: The Manager has a relaxed management approach and she relies on senior staff to delegate tasks to other carers. She agreed that there were some shortfalls in the service and that this needs to be rectified. The Manager had certificates to demonstrate that she and her senior staff regularly update their Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 16 knowledge with training via the Independent Providers Forum. She said that she has applied to do NVQ Level 4 in care. There are no systems in place to obtain service users views and be involved in decisions affecting them. Any items purchased on behalf of service users are now invoiced to them on a monthly basis with receipts being obtained for all purchases. Formal staff supervision has recently been introduced and a sample of supervision records were viewed and from these it is clear that these sessions identify training needs and good practice issues. Records were available to demonstrate that fire alarms and emergency lighting systems are regularly tested, as are electrical equipment and systems. There was no evidence to show that regular fire drills are carried out and this must be addressed. Service users care plans showed that carers lift service users from the floor and this puts them at risk. Appropriate lifting equipment needs to be provided to enable staff to safely lift service users. Use of equipment needs to be included in manual handling training. Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 2 2 x 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 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x 3 3 STAFFING Standard No Score 27 x 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 1 x x 3 3 x 2 Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 18 yes 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 1 Regulation 4 (1) (2) and 5 (1) (2) 5 (1) (b) Requirement The statement of purpose and service users guide needs to be reviewed to accurately reflect the services offered. Service users contract and terms and conditions need to incude all the information listed under the standard. Pre-admission documents must contain all aspects as listed under the standard. The home needs to demonstrate that it can meet service users assessed needs. Service users care plans need to 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). Risk assessments must be undertaken for those service users at risk of falls, who drink alcohol or have particular disabilities. Assessments must include the management of identified risks. Timescale for action 22.07.05 2. 2 22.07.05 3. 4. 5. 3 4 7 14 (1) (ac) (2) (a&b) 12 (1) (a&b) and 14 (1) (d) 13 (4) (b&c) and 15 (2) (b&c) 22.07.05 22.07.05 22.07.05 6. 7 13 (4) (b) and 12 (1) (a&b(2) 22.07.05 Marshview H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 19 7. 7 8. 8 9. 9 10. 9 11. 29 15 (1) and Schedule 3 Reg 17 (1) (a) Schedule 3 (o) and 12 (1) (a&b) and 13 (1) (b) 12 (2) (3) (4) (a) and 13 (4) (a-c) Reg 17 (1) (a) Schedule 3 (k) and 13 (1) (b) (2) Schedule 4 24 (1) (a&b) and 12 (2) (3) 13 (4) (ac) (5) 23 (4) (e) Service users care plans must inlcude all the information as listed under Schedule 3 of the Regulations. That action be taken when service users are noted to have lost weight or have a particular health problem. 22.07.05 22.05.05 That service users be given the opportunity to self medicate within a risk assessed framework. That all medication administered is recorded and given at the prescribed times. 22.05.05 22.05.05 12. 32 13. 14. 38 38 That documentation relating to staff recruitment is held on the premises and available for inspection. That regular service users meetings be carried out and minutes made available for inspection. That equipment be provided to enable staff to safely lift service users. That regular fire drills be carried out for all staff. 22.05.05 22.07.05 22.08.05 22.05.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 31 Good Practice Recommendations That the Manager undertakes training to NVQ Level 4 in care. H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 20 Marshview Commission for Social Care Inspection 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 H59-H10 s21161 Marshview v215808 220405 stage 4.1.doc Version 1.20 Page 21 - 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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