Inspection on 24/01/06 for Marston Court

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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

Marston Court 08/10/07

Marston Court 08/05/06

Marston Court 24/08/05

Marston Court 28/02/05

Marston Court 19/08/04

Marston Court 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Marston Court Marston Road Oxford Oxfordshire OX1 1ND Lead Inspector Jane Handscombe Unannounced Inspection 24th January 2006 11:00 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 Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marston Court Address Marston Road Oxford Oxfordshire OX1 1ND 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) 01865 241526 01865 722290 The Orders Of St John Care Trust Mrs Theresa Jean Whitford Care Home 39 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (20), Learning disability over 65 years of age (3), Old age, not falling within any other category (39), Physical disability over 65 years of age (20) Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 39. 24th August 2005 Date of last inspection Brief Description of the Service: Marston Court is a care home providing personal care and accommodation for 39 older people and Day care facilities for 10 from the local community. There is provision for 6 service users who need help with rehabilitation (intermediate care). The care home is managed by The Orders of St John Care Trust who are responsible for many care homes throughout the county of Oxfordshire. Marston Court is located in a residential area of Oxford approximately a mile from the city centre. Local shops, churches, pubs and other amenities are accessible to service users. Marston Court is a two storey building served by a lift. With the exception of one double room, all rooms are single with shared bathroom facilities. The care home is divided into four wings, each having a lounge and dining area. The grounds are shared with the county office of The Orders of St John Care Trust providing some lawn and a secluded patio area with a water feature. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 24th January 2006. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents in order to ascertain their views upon the care and the services they receive at the home, the staff members and the manager of the home, viewing care plans and assessments, whilst observing the general day to day operations of the home. The home presented as one which was clean and tidy throughout. Residents were going about their daily activities in a calm, relaxed manner. Staff were seen to provide care and support in an unhurried manner whilst addressing their needs appropriately. Comments received from residents during the inspection included: ‘If we need anything, the manager is very good and will sort it out’ ‘Its very nice here’ ‘we are very satisfied’ ‘very good, very nice, I do like it here’ The inspector would like to thank the residents, staff and the owner for their warm welcome and their assistance during the inspection process. What the service does well: The home is maintained to a good standard and provides a warm homely atmosphere. Staff were observed to work well as a team and were seen to be respectful and interact with the residents in a manner that was thoughtful and considerate of their needs. Meals provided at the home are well balanced, varied, offer choice and are well presented. All residents spoken to were complimentary of the meals provided at the home. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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 DS0000013159.V279322.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Prospective service users are provided with good clear information about the home and the services it offers, which along with an assessment of needs, enables them to make an informed choice when deciding upon a home that suits their needs and expectations. EVIDENCE: Information about the home is contained in a brochure which contains the Statement of Purpose and Service Users Guide and was on view within the home; it was very informative, written in plain English and easily understood. All prospective service users undergo an assessment of needs and are provided with the opportunity to spend a day at the home to meet with fellow residents and the staff, in order that they are able to make an informed choice when choosing where to live. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 The care planning system was found to be of poor quality within the home with omissions of important information, because of this it is unclear if assessed care needs are being met. The nutritional needs of the residents are not being fully assessed. Poor practices around the administration and recording of medication were apparent. EVIDENCE: The inspector viewed four residents’ care plans and found them to be of poor quality, with a lack of manual handling and risk assessments being undertaken. The lack of risk assessments informs the inspector that unnecessary risks to the residents are not being identified and as far as possible eliminated, for which a requirement has been made. Nutritional assessments were not always being fully assessed and photographs of residents were not being held on each file as is required. One resident who was admitted to the home some 4 days previous to the inspection had not undergone a moving and handling assessment and the file Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 10 was incomplete. An immediate requirement was made to ensure a risk assessment was undertaken within 48 hours. Confirmation that this had been undertaken was received by the Inspector. The home’s monthly reviews of care were not seen to be adhered to in all cases. Furthermore, all four viewed failed to contain the signature of either the assessor, or that of the resident to show that they had been involved in the process. The inspector accompanied a care leader on a medication round during the visit and found that all the residents’ medication administered the previous evening on Cherwell Unit had not been signed for, to evidence that these had actually been administered. Upon enquiry it was found that the medications had in fact been given. The same omissions were found to have taken place on Windrush that same evening. The registered manager must ensure that all staff adhere to the policies and procedures around the administration and recording of medications in order to protect the health, safety and welfare of residents in their care and ensure that there is no mishandling of medication. Requirements have been made within this report to address these issues. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 There is little opportunity for residents to take part in social or recreational activities due to lack of staff hours available to this part of the care provision. EVIDENCE: Residents spoken to during the inspection informed the inspector that the provision of recreational activities was lacking. In discussion with the manager, it became apparent that the home is in the process of advertising for an activities co-ordinator. Meanwhile, whilst the day centre has vacancies, residents are invited to join the day centre clients to engage in recreational activities, however numbers are limited. This is not an ideal situation, however the manager informed the inspector that she is in the process of advertising for an activities co-ordinator, which should allow for more activities available on a regular basis. A good practice recommendation is listed in the relevant section of this report. Residents are encouraged to pursue their religious interests if they so wish; Holy Communion and church readings are on offer for those who require them, which is delivered by two sisters who visit the home regularly on Sunday mornings. Likewise, residents are invited to attend the Marston United Reform Church, who conduct services and a range of social events for those wishing to attend, which include coffee mornings, bible and prayer groups and befriending. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 12 Meals provided at the home are well balanced, varied, offer choice and are well presented. All residents spoken to were complimentary of the meals provided at the home. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and relatives said they were happy to raise any issues with the staff or manager and that they felt any concerns would be acted upon promptly. Staff spoken to were clear about their responsibilities in relation to “whistle blowing” should they have any concerns and that this formed part of their ongoing training. EVIDENCE: All staff have attended abuse training and have been provided with the Oxfordshire Multi-Agency Codes of Practice for the protection of all vulnerable adults from abuse, exploitation and mistreatment and are clear about their responsibilities. The complaints procedure was found to be on display upon notice boards within the home, allowing residents, their families, friends and visitors to the home, access to the procedure; however the contact details were handwritten and could be difficult for those with poor eyesight to read. It is recommended that the complaints procedure be updated to include printed contact details for easier reading. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 24 An ongoing programme of redecoration and routine maintenance is in place and creates a comfortable and safe environment for the residents and their visitors to enjoy. EVIDENCE: On the day of the inspection, the home was clean and tidy with a homely atmosphere. Residents’ bedrooms are furnished and equipped ensuring comfort and privacy and meeting their assessed needs. The manager informed the inspector that the home encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking if required and this was evident on touring the home. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 15 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): 28, 29 and 30 The home’s recruitment and selection of staff operates in line with equal opportunities and is non-discriminatory. Checks are undertaken on staff to ensure their suitability and residents’ protection, as are references, although shortfalls were found in one case around references. (See below) All staff undergo an induction period when commencing at the home, are provided with further training, supervision and appraisals to ensure they are equipped with the skills and knowledge to undertake their role competently. EVIDENCE: A sample of staff records was viewed and found to be incomplete, one did not evidence that 2 references had been sought and three failed to contain written records of the interview. Supervisions were found to be due for updating, which the inspector was informed was being undertaken and due to be complete by the end of the month. A further two failed to evidence that their appraisals had been undertaken; however the inspector was informed that they were due and that these would be updated accordingly. Staff spoken to during the inspection confirmed that they undergo an appraisal once a year and regular supervision takes place both formally and informally. Mandatory training was found to be out of date for a couple of care staff and a requirement has been made to ensure that all care staff receive updating of their mandatory training at the appropriate intervals. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 16 All new staff receive a two day off site induction within 6 weeks of starting which includes manual handling, first aid and food hygiene training. All care staff are encouraged to undertake the National Vocational Qualification (NVQ) in care. Four care staff are presently signed up to undertake their NVQ level 2 and a further three for the NVQ level 3. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 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, 33, 35 and 38 In view of the findings during the inspection around assessment of needs, risk assessments, and the recording of administered medication, the inspector is of the view that the home is not presently protecting the health, safety and welfare of the residents appropriately, and is therefore not being run in the best interests of those using the service. There are clear robust systems in place to protect the residents’ financial interest. EVIDENCE: There are shortfalls around the residents’ health, safety and welfare (see section headed Health and Personal Care) which were also evident during the last couple of inspections and for which requirements were made. The home must ensure that assessments and individual plans of care and reviews are comprehensive and address the needs of the residents appropriately. Continued failure to comply with this could result in enforcement action. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 18 The inspector met with the administrator and discussed the management of the residents’ finances. The systems and records were examined and found to be in good order and provided a clear audit trail to safeguard the residents’ financial interest. The manager is presently undertaking the Registered Managers Award and NVQ level 4 in care which should be completed in the very near future. The manager is clear regarding her roles and responsibilities and has a supportive line management structure. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 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 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x x STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 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 OP7 Regulation 24(1)a Requirement Timescale for action 25/01/06 2 OP3 17(1)a Schedule 3 3 OP3 14(1)a,c 4 OP7 24(1)a The registered manager must ensure to undertake a risk assessment and manual handling assessment for the resident identified during the inspection, within 24 hours and confirmation be forwarded to CSCI. The Registered Manager must 21/02/06 ensure that a photograph of each service user be kept on file. This is an outstanding requirement from previous inspections in February and August 2005. The Registered Manager must 21/02/06 ensure to gain a signature to evidence that the resident/representative has been involved in the assessing and care plan procedure and the assessment has been undertaken by a person qualified to do so. This is an outstanding requirement from previous inspections in February and August 2005 The Registered Manager must 28/02/06 ensure that all risk assessments are undertaken and kept up to DS0000013159.V279322.R01.S.doc Version 5.1 Marston Court Page 21 5 OP29 19 Schedule 2 6 OP30 18 date to reflect the needs of the service users, and to provide staff with clear information as to the management of those needs. This is an outstanding requirement from previous inspections in February and August 2005. The registered manager must ensure to operate a thorough recruitment procedure and gain 2 written references and hold these on staff members’ personnel files All care staff must receive updating of their mandatory training at the appropriate intervals. 28/02/06 01/04/06 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 OP7 OP12 OP16 Good Practice Recommendations It is recommended that all care plans be reviewed once a month, with the involvement of the resident and/or their representative. It is recommended that the seeking of an activities coordinator is of priority in order that residents are enabled to partake within an increased activity programme. It is recommended that the complaints procedure be updated to include printed contact details for easier reading. Marston Court DS0000013159.V279322.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000013159.V279322.R01.S.doc Version 5.1 Page 23 - 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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