Inspection on 06/06/07 for Marshview

This inspection was carried out on 6th June 2007.

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 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 16/05/06

Marshview 19/09/05

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 Key Unannounced Inspection 09:00 6th June 2007 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.V339716.R01.S.doc Version 5.2 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.V339716.R01.S.doc Version 5.2 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 Marshview@beamingmail.com 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.V339716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is seventeen (17). Service users must be older people aged sixty-five (65) years or over on admission. That up to two service users with a dementia-type illness may be accommodated within the total registration of seventeen (17). 16th May 2006 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. Accommodation comprises eleven single rooms and three double rooms, of which one has en-suite toilet facilities. 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 at least a hand washbasin. None of the rooms have full en-suite facilities but there are sufficient communal toilet and bathing facilities to meet service users needs. Information about the service, including the Statement of Purpose, Resident’s Handbook (Service User’s Guide) and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The range of weekly fees from April 2007, is £350- £480. Additional charges, not included in the fees, include hairdressing, chiropody, newspapers and transport. Intermediate care is not provided. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit and its purpose was to check compliance with key standards and to check compliance with shortfalls identified at the last visit. There were fourteen people in residence on the day of which five were spoken with. The Registered Manager and her deputy were also spoken with in addition to two relatives who were visiting on the day. Two relatives were contacted following the site visit and four surveys were returned one of which was completed by a person living in the home. Responses to the survey questions were generally positive about all aspects of the service, with staffing levels being the one area for concern. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Prior to the site visit the registered provider provided a pre-inspection document and the information given is included in relevant parts of this report. Surveys from relatives and those spoken with included comments such as: ‘always unfailing kindness – worth its weight in gold’. ‘Maybe employ more staff’ ‘The staff are always polite and caring to dad at all times’ (the home) ‘Usually clean and fresh’ ‘they get good care and the food is fine’. ‘I’m always made welcome and offered refreshments’. ‘I feel dads needs are met’. What the service does well: What has improved since the last inspection? What they could do better: Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 6 Pre-admission assessments should be completed in full and in consultation with the service user or a representative, to ensure that an individual’s care and support needs have been identified before moving into the home. Improvements need to be made to the care planning process to ensure care plans provide clear direction to staff in the delivery of care in a structured and consistent manner. It is also essential that care plans are reviewed and updated, to accurately reflect the service user’s current and changing needs and in conjunction with the daily notes. Those living in the home should be consulted regarding their social and leisure interests and an activities programme be implemented to reflect their interests and preferences. All parts of the home need to be kept free from offensive odours and people moving into the home enabled to bring their own furniture. Staffing levels should be kept under review, to ensure that the needs of those living in the home are met in full. Formal quality monitoring systems need to be further developed to enable the Registered Provider to objectively evaluate the service and take appropriate action as required to improve the delivery of care within the home. 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. The summary of this inspection report can be made available in other formats on request. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4. Standard 6 is not applicable. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the pre-admission assessment to demonstrate that the home can meet the needs of people admitted to the home. EVIDENCE: Pre admission sheets for those people recently admitted to the home were viewed and one was found to be incomplete. In order for the home to demonstrate it can meet the needs of those people admitted to the home all care needs need to be identified and information is provided to demonstrate how those needs will be met. The home provides details of the complaints procedure, a statement of purpose and a contract prior to anyone being admitted to the home. One relative spoken with said that they had received information verbally and in writing prior to their family member being admitted. Intermediate care is not provided. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care planning systems do not fully reflect the current health and personal needs of those living in the home, but systems for safe handling of medication are good. EVIDENCE: Five care plans were viewed and while improvements were noted, there remain shortfalls in this process that need to be addressed to ensure the current needs of those living in the home are identified and planned for. Although people living in the home are weighed regularly there is no follow up action to direct staff when individuals have lost or gained weight. It is important that those living in the home are consulted on the contents of their individual plan and agree the contents. Although the care plans stated that individuals had been consulted not all had been signed to demonstrate this had occurred. An optician and chiropodist regularly visit the home and other healthcare professionals are consulted as required. Comments from those living in the home included: ‘they (staff) are very kind’. ‘I feel well looked after’. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 10 ‘still well looked after’ ‘staff are very nice’. In viewing care plans and observing those living it the home it is clear that the dependency of some individuals in terms of their physical needs is such that the home may not be able to meet those needs with existing staffing levels therefore a reassessment is necessary. The daily notes included references to the needs of some people living in the home, however these were not added to the care plans nor was there clear records as to how these identified needs were met. Risk assessments have improved and now need to be regularly reviewed to include any increased risk or changes in needs with particular attention for those at risk of falls , with impaired vision or tissue breakdown. Risk assessments also need to include what action staff need to take to reduce risk. Staff were seen to dispense medication in line with the homes policies and procedures and medication records were clear, accurate and up-to-date. There are systems in place to ensure there is a clear audit trail of all medications held in the home. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle of people living in the home does not fully match their expectations in respect of activities, but contact with family and friends and meals are satisfactory. EVIDENCE: The home has an activities programme and a carer was observed to initiate a game, chosen by those living in the home and it was evident that the game was much enjoyed. However, the activity programme is not based on the preferences of those living in the home and some activities are repeated more than once during the week. Care plans showed that leisure preferences of individuals had been identified but there was no evidence to demonstrate what action the home will take to enable them to continue with preferred leisure interests. One care plan stated that the person liked to go for walks and that they were to be taken for daily walks, but there was no evidence to show that these walks had been provided, nor who would be responsible for accompanying him. During the afternoon a carer played some music but did not ask the people in the lounge if they wanted music on nor did she give them a choice of music. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 12 This needs to be addressed to ensure that those living in the home are given choices whenever possible. All relatives spoken with confirmed that they are made welcome at the home and were encouraged to visit at all times. One relative regularly takes her mother home for the day or on outings and this is encouraged by the home. Comments from those living in the home included: ‘the food is excellent’ ‘its ok here – not much to do but the staff are very kind’. ‘ I still manage to get out to meetings but no so much now due to bad legs’. ‘we don’t have many activities here’. ‘I don’t get out much’. Menus showed that meals are wholesome, nutritious, varied and balanced. People spoken with said that the meals were good and they were offered a choice for both the lunchtime and supper menus. Two people living in the home said that there was not much choice of dessert and that they are never given fresh fruit. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a detailed complaints system with evidence that concerns are listened to and acted upon, those living in the home are further protected by satisfactory adult protection policies and procedures. EVIDENCE: The home has detailed policies and procedures on complaints and the complaints records received showed that any concerns raised are acted upon in line with those policies and procedures. There are detailed adult protection policies and procedures and all staff have been trained in adult protection procedures. The Registered Manager and her deputy are knowledgeable about adult protection and ensure all those living in the home are safe. An appropriate adult protection alert was made in line with the homes policies and procedures and the matter has now been resolved satisfactorily. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained provides a homely and comfortable environment; improvements need to be made to ensure all areas of the home are free from offensive odours. EVIDENCE: On arrival there was very strong odour of urine throughout the home and some rooms were also malodorous. This was discussed with Registered Manager who explained that she was aware of this and that the cleaner would deal with it when she came on duty. Eliminating offensive odours needs to be addressed to ensure that the environment is pleasant at all times. Generally, individual bedrooms were tidy and nicely decorated and some had taken the opportunity to personalise their rooms with photographs and ornaments, although others were more stark and one relative said they were not allowed to bring in their own furniture. This practice needs to be reviewed to enable all those living in the home to have their chosen furniture in their rooms. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 15 Information provided by the home prior to the site visit indicated that all staff have been trained in infection control and they were observed to work in was that minimise cross contamination by wearing gloves and aprons as required. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff recruitment and training is robust and thorough and ensures people living in the home are not at risk. To ensure the needs of all people living in the home are fully met a review of staffing levels based on their needs, must to be carried out. EVIDENCE: There are two carers on duty for each daytime shift and one at night. In addition there is the Registered Manager and her deputy available during the day. Given that one person living in the home needs two staff for all transfers staffing levels need to be reviewed to ensure that the home can meet the needs of everyone living in the home. Cooks and domestic staff are also employed in the home. The manager continues to cover for staff sickness and holidays and is often directly involved in care provision. When not actually on the premises, she is on call. Comments from those living in the home and relatives spoken with included: ‘the staff are very nice’. ‘I am very satisfied with the care’ ‘I cant fault them’. Recruitment records were found to be generally well maintained, containing necessary information, including two written references and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 17 disclosures. A full employment history needs to be provided to ensure the home fully complies with the standards. Information provided prior to the site visit indicated that all staff have an induction period, followed by a foundation training programme that ensures they have the skills and competence to deliver good quality care. Of the 10 care staff, 4 currently have an National Vocational Qualification level 2 in care. Three other staff are working towards achieving this qualification so the home is on target to achieve 50 of care staff with this qualification. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from an open leadership style however improvements need to be made to ensure the home is run in their best interests and all aspects of their safety protected. EVIDENCE: The Registered Manager has both a care and management qualification that meets the required standard. In addition she has many years experience in the care industry and is knowledgeable about the client group. She has an open management style and it was observed that those living in the home, staff and visitors are comfortable approaching her with any concerns. The Registered Manager arranges regular meetings to consult with those living in the home and staff to ensure their views are recorded and action taken to meet identified needs. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 19 The documents provided by the Registered Provider prior to the site visit indicated that regular safety checks are carried out on all gas and electrical appliances and systems. There were records showing the regular testing of call bells, emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. The accident book was viewed and found to be in order with all accidents recorded as required under Health and Safety guidance. The Registered Manager said that she has developed a formal quality assurance and quality monitoring system and this needs to be implemented to ensure all aspects of the service is objectively evaluated. The home does not handle the finances on behalf of those living in the home and when items are bought a receipt is obtained and the amount added to the monthly invoice. Staff training records showed all staff have been trained in fire safety, manual handling, first aid, health and safety and infection control. A fire risk assessment has been carried but needs to be updated in line with the latest fire safety guidance. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 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 X X 2 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 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 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 21 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 OP3 Regulation 14(1a-c) (2a&b) Requirement It is required that the preadmission needs assessment be completed in full and in consultation with the service user or a representative. (timescale of 31/07/06 not met). It is required that service users’ care plans set out in detail the action which needs to be taken by care staff, to ensure that all individual health, personal and social care needs are met in a structured and consistent manner. (Timescales of 19/12/05 and 31/07/06 not met). It is required that care plans be regularly reviewed and updated to accurately reflect service users current and changing needs. (Timescales of 19/12/05 and 31/07/06 not met). It is required that risk assessments are updated in respect of those service users who are at risk of tissue breakdown and falls. DS0000021161.V339716.R01.S.doc Timescale for action 06/08/07 2. OP7 15 (1) 06/08/07 3. OP7 15 (1) (2)(c) (d) 06/08/07 4 OP7 13 (4) (b)(c) 06/08/07 Marshview Version 5.2 Page 22 5 OP8 12 (1), 13 (1) & 17 (1a) 16 (2) (m & n) 6 OP12 It is required that documentary 06/08/07 evidence be provided regarding the management of possible tissue breakdown. (Timescale of 19/12/05 and 31/07/06 not met) It is required that service users 06/08/07 be consulted regarding their social and leisure interests and an activities programme be implemented to reflect those interests and preferences. (Timescale of 19/12/05 and 31/07/06 not met). It is required that staffing levels be reviewed to ensure that service users needs are met. That a fire safety risk assessment is carried out in line with latest fire safety guidance. 06/08/07 7 OP27 18 (1) (a) 8 OP38 23 (4) (a-e) 06/08/07 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 2 3 Refer to Standard OP19 OP27 OP33 Good Practice Recommendations That a review is carried out to enable service users to bring in their own furniture. It is recommended that staffing levels be kept under review to ensure that service users needs are met. That the formal quality monitoring system be implemented. Marshview DS0000021161.V339716.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339716.R01.S.doc Version 5.2 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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