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Inspection on 28/06/05 for Marston Court

Also see our care home review for Marston Court for more information

This inspection was carried out on 28th June 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The registered manager makes an excellent effort to maintain good standards of care in the home. Staff spoke positively about the approach to managing the home indicating that the approach promotes an open and inclusive atmosphere, this is also reflected in the clarity and promotion in the complaints procedure. The management team are committed to raising and maintaining good standards of care for this service based on the outcomes from this inspection. The fixtures, flooring and walls are maintained to a very high standard creating a homely environment, some areas are in need of updating and this is well reflected in the plan of maintenance compiled by the manager. A choice of meals is evident; they are varied and well presented. Daily activities are managed well and all residents previously spoken with indicated that they are satisfied with the overall care given in the home. Medication is very well managed, with the exception of one area, care plans and risk assessments are completed well with a significant amount of detail in relation to each resident.

What has improved since the last inspection?

Nothing was identified at this inspection.

What the care home could do better:

The "bulk" medication supplied by the pharmacist must be accounted for appropriately, this issue detracts from an otherwise excellent medication system in place. The registered person could ensure the regulation 26 reports are sent through appropriately; this would underpin the openness and transparency already evident in the home. Finance to rectify the necessary work to the flooring on the ground floor could have been made available before now; this would have resulted in one requirement less in the inspection report.

CARE HOME ADULTS 18-65 Marston Court 67, Marston Road Leicester Leicestershire LE1 5SG Lead Inspector Keith Williamson Unannounced 28th June 2005 at 8.30am 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 V223371 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Marston Court Address 67 Marston Road Leicester Leicestershire LE1 5SG 0116 210 3895 0116 277 7575 None Marston Court Limited 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) Mr David Bailey 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 V223371 280605 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 28/11/04 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. Marston Court C51 C01 S46220 Marston Court V223371 280605 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 8.30 am and was completed in seven 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; three 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 manager and deputy 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 but secure environment for residents’. What the service does well: What has improved since the last inspection? Nothing was identified at this inspection. Marston Court C51 C01 S46220 Marston Court V223371 280605 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 V223371 280605 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 V223371 280605 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) 1, 2, 3 & 5. The admission process is good and the assessment process is very detailed and effective, which enables the staff team to deliver appropriate care. EVIDENCE: Careful examination of the Statement of Purpose indicated that it accurately outlines the services provided in the home, however neither of the two residents spoken with, could indicate that the care is delivered according to what is written in the document. The contract is presently reproduced in pictorial and symbol form as well as in written form. Communication methods are then employed where possible based on the service users skills of comprehension to give this information to residents. There is evidence in place to indicate the use of advocates in the admission process in the home. Marston Court C51 C01 S46220 Marston Court V223371 280605 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 & 9. Residents’ care plans are written in great detail, ensuring appropriate care is given. Robust processes are in place to enable independence; good risk management enables residents to make decisions EVIDENCE: Detailed inspection of three residents’ care plans indicated that all aspects of their assessed care needs has been identified and recorded on the document, which is reviewed on a regular basis. None of the three residents could indicate that they are satisfied that their assessed care needs are being taken care of. Evidence of additional information such as behavioural monitoring paperwork was in place. Risk is assessed appropriately and also reflected in the care plans seen on the day. Two of the three care plans and risk assessments seen including detailed discussion with the registered manager indicated that the care plans have good information in setting out the actions staff members must take to meet both residents’ assessed care needs, the third plan was for a deceased resident, this also reflected appropriately the changes in the individual care plan necessary to care appropriately for the resident. Marston Court C51 C01 S46220 Marston Court V223371 280605 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) 11 & 12. The home provides good opportunities for residents to access educational and leisure facilities. EVIDENCE: A number of residents’ attend college education, which promotes basic life skills, the arts and music, and swimming; two service users also continue to attend a day centre. Marston Court C51 C01 S46220 Marston Court V223371 280605 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) 18, 19 & 20. Appropriate assistance is in place to meet residents’ hygiene and health care needs. The medication process does not ensure that residents receive correct doses of medication. EVIDENCE: Specialist support and information is obtained and then entered in the individual care plans according to the identified needs. Monthly health checks are undertaken for each service user, these include checks on blood pressure, weight and urinalysis and this is commended. The manager stated that any complications and problems are identified and dealt with at any early stage including prompt referral to an appropriate specialist if required. Service users are encouraged to take control and manage their own healthcare where possible though no residents’ currently hold any medication. There is an ongoing issue with the “stock” medication, and an inability by staff to keep records accurately, this was also evidenced at the last inspection. This has now been proved as a maladministration error, and the responsible person rectify this situation urgently. Marston Court C51 C01 S46220 Marston Court V223371 280605 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) 22 & 23. Robust processes are in place so that residents or their relatives can make complaints and adult protection procedures protect residents from all forms of abuse. EVIDENCE: Examination of the written complaint process indicated that clear guidance is given to residents and their relatives on how to make a complaint. The manager continues to provide the additional information to residents and their families to assist in any complaint about the service, this includes stamped addressed envelopes, the inspectors photograph on the staff photo board and the complaints information in a pictorial version. The adult protection process was inspected. Clear guidance is written in the adult protection policy on how to avoid the risk of vulnerable adult abuse. No residents spoken with, could express their interpretation of either of the above the policies. Marston Court C51 C01 S46220 Marston Court V223371 280605 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, 26 & 30. The home is clean, hygienic and pleasant in appearance, which creates a homely environment. EVIDENCE: The carpets to the ground floor corridors and foyer area, are very stained and in places frayed and require urgent replacement, it is recommended that an alternative flooring be considered for these areas as these carpeted areas have suffered from water damage from the entrance door and shower areas. Of the communal space in the home, namely the two lounge /dining rooms which they feel is large enough for their leisure activities. Of the bedrooms sampled at the inspection by the inspector, all are fitted out to a high standard. All the ground floor bedrooms have ceiling track hoists, and some bedrooms have specialist beds and all are personalised An inspection of the premises indicated that it is clean and hygienic in appearance. Marston Court C51 C01 S46220 Marston Court V223371 280605 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) 33 The care hours provided is sufficient to provide suitable care and protection for residents on a daily basis. EVIDENCE: A calculation of staffing hours using the Residential Forum for Younger Adults indicated that the staffing rota was adequate to meet the current group of residents. Marston Court C51 C01 S46220 Marston Court V223371 280605 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) 40, 41 & 42. The procedures and written policies seen are satisfactory in providing good guidance for staff members. Good record keeping is maintained in the home to ensure safety and privacy. EVIDENCE: A number of written documents were inspected, namely the medication, infection control, complaints and adult protection policies staff members on duty displayed good verbal knowledge concerning the content of the policies. Examination of the care records, care plans and daily records indicated that records are being kept in accordance with the Data Protection Act 1998 and the Care Homes Regulations 2001. A copy of the recorded visits by the registered person to the home are produced but not forwarded appropriately to the inspector, this is still an outstanding requirement form the last inspection; as is the need for a copy of the business plan. Marston Court C51 C01 S46220 Marston Court V223371 280605 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 3 4 x 3 4 Standard No 22 23 ENVIRONMENT Score 4 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x x x Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Marston Court Score 3 4 2 x Standard No 37 38 39 40 41 42 43 Score x x x 3 3 x 2 C51 C01 S46220 Marston Court V223371 280605 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. Standard 20 Regulation 13(1) Requirement Timescale for action 28/8/05 2. 24 23(2) 3. 43 25(2) 4. 43 26(4) The registered person must ensure accurate stock records of medication are kept in the home. This requirement is outstanding from the last inspection. The registered person must 28/9/05 ensure the carpets in the foyer and ground floor areas of the home are replaced. The registered person must 28/8/05 ensure the business plan is available at future inspections. This requirement is outstanding from the last inspection. The registered person must 28/8/05 commence sending a copy of their visits to the home. This requirement is outstanding from the last inspection. 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 24 Good Practice Recommendations It is recommended that the registered person considers alternative flooring for the foyer and ground floor areas of C51 C01 S46220 Marston Court V223371 280605 Stage 4.doc Version 1.40 Page 18 Marston Court the home. Marston Court C51 C01 S46220 Marston Court V223371 280605 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 V223371 280605 Stage 4.doc Version 1.40 Page 20 - 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!