CARE HOME ADULTS 18-65
Marston Court 67 Marston Road Leicester Leicestershire LE4 9FF Lead Inspector
Keith Williamson Unannounced 17 August 2005 at 9.00am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Marston Court Address 67 Marston Road Leicester Leicestershire LE4 9FF 0116 2103895 0116 277 7575 None Marston Court Limted 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) Vacant Care Home 16 Category(ies) of LD - Learning Disability - 16 registration, with number PD - Physical Disability - 16 of places Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: No person falling within the category PD may be admitted to the home unless that person also falls within category LD, i.e. dual disability. Date of last inspection 28/06/05 Brief Description of the Service: Marston Court is a purpose built property, registered to provide care for sixteen younger adults with learning difficulties and physical disabilities. It is situated in a residential street within a multi-cultural setting. The home consists of the ground and first floor, which is served by an integral lift. The home was purpose built and has been operational since 2002. There are local amenities within ten minute walking distance and social activities within reasonable proximity to the home. Service users do not go out unaccompanied. The home has purchased a mini–bus with internal adaptations to provide transport for outings and holidays for the residents. The home has a good mix of trained staff of both genders and differing cultural backgrounds. The staff provide many activities in and outside of the home including holidays away from the home. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day, commenced at 9.00 am and was completed in four hours by one Inspector. An opportunity was taken to view the care plans and other records in detail. Two residents were spoken with on this visit, however none made comments applicable to the Inspection visit; two staff were also spoken with. No questionnaires were returned to the Inspector prior to the Inspection process, these shall be collated and responses studied for the next inspection of this service later in 2005/06. The deputy manager assisted with the Inspection, spending time with the Inspector discussing the management of the home. Overall the Inspector recognised the home, continues to function very well and provides a homely and secure environment for residents’. What the service does well: What has improved since the last inspection?
The “bulk” medication supplied by the pharmacist is now accounted for appropriately, the medication system is now administered securely. The necessary work to the flooring on the ground floor has commenced, prior to the date required in the last inspection report.
Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 6 What they could do better: 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. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None. No standards in this section were viewed on this occasion. EVIDENCE: Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 7. Residents’ care plans are written in detail, and decision-making is recognised appropriately ensuring suitable care is given. EVIDENCE: Detailed inspection of two residents’ care plans indicated that all aspects of their assessed care needs has been identified and recorded in the document. Care plans are reviewed on a regular basis. The Inspector discussed the home with one resident who recently had a birthday celebration and indicated she was “looking forward to Christmas”. Evidence of additional information such as behavioural monitoring information was in place. Risk is assessed appropriately and on am individual basis. Decision-making is recognised appropriately within the group, pictorial choices and prompts are offered throughout the home, decisions on what choices residents make, or where choice is assisted are appropriately recorded in care records. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 15, 16 & 17. A range of appropriate lifestyle and personal development choices are offered ensuring good quality care is delivered. EVIDENCE: A number of residents’ attend college education, which promotes basic life skills, the arts and music, and swimming. A number of residents access community activities and leisure facilities on a daily basis. This should be enhanced with the proposed employment of a “day care” co-ordinator. Daily routines are centred round plans of care, which agreed with residents or their representatives in advance. Residents are encouraged to keep up family relationships with visiting being encouraged openly. A cook is employed who compiles the menus in advance taking into consideration cultural and dietary preferences. A wealth of further information is available to staff with regard to Speech and Language Therapy (salt) and “safe eating” assessments ensuring staff have all the information necessary to ensure residents have the appropriate levels of dietary intervention and safety. This is a recent addition and is seen as very good practice.
Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20. The medication process now ensures that residents receive correct doses of medication. EVIDENCE: The ongoing issue with the “stock” medication, and an inability by staff to keep records accurately was evident at the last two inspections. This has now been rectified and the medication system is monitored and administered appropriately. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None No standards in this section were viewed on this occasion. EVIDENCE: Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24. The home is clean, hygienic and pleasant in appearance, which creates a homely environment. EVIDENCE: The stained carpets to the ground floor corridors and foyer area were in need of urgent replacement. It was recommended that alternative flooring be considered for these areas as these carpeted areas had suffered from water damage from the entrance door and shower areas. Both areas were replaced prior to the required date. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35. A number of training courses are provided for staff ensuring an effective staff group. EVIDENCE: Evidence is apparent of the courses offered to all designations of staff in the home. Individual certificates are in evidence in staff files. Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 43. Residents and their representatives are consulted and involved in the running of the home. Security of the home is not reviewed regularly. EVIDENCE: Effective quality monitoring systems are in place in the home. Questionnaires are issued periodically to a range of individuals who visit and support the home; the deputy manager stated the outcomes of these should be added at the next review of the Statement of Purpose and Service User Guide. The business plan for the home is now in place, though regulation 26 reports have yet to commence on a regular basis. An immediate requirement was left over perimeter security, as building work is going on at an adjacent property. A recent theft from the property should have prompted a review of security, and this immediate requirement was the result of a lack of action by the Responsible Individual. The Responsible Individual must also ensure the appropriate reporting of such incidents to the appropriate authority.
Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 x 3 3 4 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Marston Court Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 17 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. 2. Standard 42 42 Regulation 26(4) 26(4) Requirement The responsible individual must ensure the safety of residents and staff in the home. The responsible individual must commence sending a copy of the regulation 26 visits to the home.This requirement is outstanding from the last inspection. The responsible individual must ensure all events under regulation 37 are forwarded to the CSCI. Timescale for action 17th August 2005. 13th September 2005. 3. 42 37 13th September 2005. 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 Good Practice Recommendations Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire 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 Marston Court C51 C01 S46220 Marston Court V243592 170805 Stage 4.doc Version 1.40 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
