Inspection on 22/04/05 for Martin Hall Nursing Home

This inspection was carried out on 22nd April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Martin Hall Nursing Home 06/07/06

Martin Hall Nursing Home 27/10/05

Martin Hall Nursing Home 19/08/04

Martin Hall Nursing Home 29/04/04

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

CARE HOMES FOR OLDER PEOPLE Martin Hall Nursing Home The Old Hall Martin Lincs LN4 3QY Lead Inspector Sue Daniells Unannounced 22 April 2005 10:00am 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 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. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Martin Hall Address The Old Hall Martin Lincs LN4 3QY 01526 378251 01526 378250 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 M Peck Peck & Packer (Care Homes) ltd Ms L Layton Care Home with Nursing 40 Category(ies) of DE (E) 39 registration, with number MD (E) 40 of places DE 2 Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered to provide care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder, excluding learning disability or dementia -over 65 years of age (MD(E)) (40). Dementia - over 65 years of age (DE(E)) (39) Dementia - (DE) (2) for service users aged between 60 years and 65 years The maximum number of service users in the home with nursing needs does not exceed 29 and the maximum number of service users with personal care needs only does not exceed 11. Date of last inspection 19th August 2004 Brief Description of the Service: Martin Hall is situated in its own grounds in the village of Martin-byTimberland, which is on the main road between Lincoln and Woodhall Spa. Local amenities include village shop/post office, church, village hall and public house. A local bus service passes through the village every hour and runs between Boston and Lincoln.The home can accommodate up to 40 service users with mental health needs, either nursing or residential. Bedrooms are on the ground and first floor and comprise 24 single rooms, 15 of which are en-suite and 8 shared rooms, all of which are en-suite. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours with 29 service users receiving nursing care and 10, personal care only. The main method of inspection used was “case tracking”. This involved selecting three service users and looking at the care that they received through the checking of their records, discussion with them and the care staff and looking at the care they receive. Discussions were also had with three relatives and a member of the domestic staff: parts of the home were also visited including the laundry. The inspector was also able to see the majority of service users in the home and observe the care that they received from the staff. What the service does well: What has improved since the last inspection? The home has taken action to put right some of the things that were noticed during the last inspection including the information given to prospective service users and their families. The complaints policy has also been brought up to date. The décor and furnishings have also improved in the home, with a conservatory being added to a small communal room Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 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. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3. Standard 6 does not apply as the home does not provide an intermediate care service. There is sufficient satisfactory information to enable prospective service users and their families to make an informed choice about the home and although pre-admission assessments are undertaken, these could be improved. Contracts between the home and the service user, for the care delivered, are not comprehensive and service users or their family’s are currently not informed that the home can meet their needs before admission. EVIDENCE: The Statement of Purpose and Service User Guide, which provide information about the home to prospective service users and their family’s, were available at the time of the inspection. The Statement of Purpose included the relevant experience of the provider and manager, which was not available at the last inspection. The manager stated that the Service User Guide is sent or given to everyone who enquires about the home: this document included the last inspection report. A relative spoken to stated “We made the right choice” Resident’s records included contractual information, although these did not include the fees payable and by whom. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 9 Pre-admission assessment of needs were available for service users, although it has been recommended that more details are covered in order that they are as comprehensive as possible. Letters from the home to prospective service user’s and/or their family, assuring them that the home can meet their needs, had not been written. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Care plans are not always written as soon as possible after admission nor do they always reflect all the care that is required, which places service users at possible risk, although relatives could not fault the care given. Service user’s privacy and dignity is respected and their healthcare needs are met. Satisfactory policies and procedures for all aspects of medication are in place, although the recording of the administration of drugs is not always up-to— date. EVIDENCE: Two service users, admitted in the previous two weeks, did not have care plans produced by the home, although the pre-admission assessments were in place and daily records were in evidence. The one care plan that was available did not show all the care needs of the service user. Two service users did not have risk-assessments, one of them having a history of falls. It was agreed by the manager at the conclusion of the inspection that the two care plans would be drawn up immediately. From the records available, it was evidenced that service users have access to all health care services when it is required. Evidence of GP visits was in the Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 11 daily reports and at the time of the inspection a GP visited the home to undertake examinations of a number of her clients. She visits on a regular basis and also goes to the home when requested. The manager and staff stated that they have a good relationship with the local doctors, and community nurses visit the service users who require personal care only. The manager did raise concerns regarding the availability of dentists; the home currently uses a combination of the community dentist, a private dentist and one providing NHS care, but she feels this is not satisfactory. Policies and procedures for all aspects dealing with the ordering, administration and disposal of medication were available. Service users in the home are not able to self-medicate because of their complex care needs. The drug trolley was examined and the contents were found to be stored satisfactorily. Temazepam, a schedule 3 drug, was found to be correctly stored in the Controlled Drug (CD) cupboard. The number seen tallied with the balance in the CD book. There were, however, a number of signatures missing from the medicine administration records (MAR charts) for service users. A similar situation was found during the last inspection. The cupboard used for stock drugs was found to be in order with drugs date rotated. Relatives of two service users stated that they had always found that their loved ones privacy and dignity were respected and staff spoken to gave the inspector details of how they would ensure that service user’s privacy and dignity were protected. “We always make sure doors are shut and curtains are closed when we undertake personal tasks for the residents” was a statement made. During the inspection the inspector was also able to observe the way the staff treated the service users and this was found to be satisfactory. The relatives spoken to were very complimentary of the care that service users received, with comments such as “the care is excellent and they really do care” and “we can’t fault the care and they kept us informed of his illness, the GP visits and his treatment” Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 14 The home welcomes visits from friends and relatives and service users are able to enjoy trips out when they are well enough to go. For some service users, exercising choice and control over their lives may be difficult, but they are given support by the staff to do this. EVIDENCE: Staff informed the inspector that service users who were able, attended their local “Derby and Joan” club and that when the weather was nice they were able to go out in the mini-bus to such places as Skegness, Woodhall Spa and garden centres. They are also able to go to the local pubs for a lunch and a drink. However, it is recognised that the number who are able to go would be limited. Visits from friends and relatives is encouraged at any time of the day and relatives visiting stated that they are always welcomed. Although no-one currently goes to church, both the Church of England and the Roman Catholic clergy visit the home on a regular basis and the manager stated that if anyone wishes to go to church services they would ensure that transport was provided. On an occasional basis, clothing and shoe firms visit the home and a mobile library brings books. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 13 Two of the three relatives said that although they are only able to visit once a week, they know that there are activities and that the local children visit to act out plays. It was not possible to gain evidence from service users. The staff spoken to stated that they try and ensure service users have as much choice over their lives as they can, which includes the clothes they wear, where they sit and what they do during the day. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a complaints policy and procedure and deals with complaints in a satisfactory manner. EVIDENCE: The home has a complaints policy and procedure, which has recently been updated. The home had received one complaint in the past eight months, which had also been sent to the Commission. The complaint regarding the care of a relative had been passed back to the home to investigate and was found to be unsubstantiated. The complainant was informed of the outcome by letter but has not replied or visited the home since. The manager stated that all service users and relatives are given a copy of the procedure and the relatives spoken to stated that they were aware of the procedure and would contact the manager if they had any issues. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is undergoing a programme of decoration and refurbishment and provides a homely environment for the service users. The home was found to be clean and tidy and laundry is dealt with appropriately, according to the policies and procedures in place. EVIDENCE: During the visit, the inspector toured the building and it was seen that the home had recently had a conservatory added to a small lounge. The room has provided a welcome addition to the communal space in the home and will provide service users the ability to enjoy the sunshine during the colder months of the year with blinds being ordered in order to protect furnishings and service users from the heat during the summer months. Since the last inspection, a programme of upgrading in bedrooms and corridors has been undertaken which has improved the home and the manager stated that this would be ongoing. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 16 However, it was noted that the furniture in the main dining room needed replacing. The manager stated that this was on a list of “things to be done” and would be undertaken as soon as possible. On the day of the visit, the home was found to be clean and policies and procedures for the control of infection were in place. The laundry is well equipped with the person responsible for it having recently attended an infection control study day, which they had found to be extremely useful. Relatives spoken to stated that they felt the home was always clean and tidy, although one member of staff said that they thought care staff could spend a little more time tidying service user’s bedrooms. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Service users are put at risk because of a lack of attention to the detail of recruitment. EVIDENCE: Files for three staff members recruited since 2002 were examined. Although the home has a recruitment and selection policy and procedure, it was found that a photo was not present in one and only one reference was available for another. This issue was identified at the last inspection and has therefore not been addressed. The application forms do not allow for a full employment history; currently there is only room for three previous employers. Interview documentation provides space for notes to be made, although this had not been used. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37 and 38 Induction and supervision is not as comprehensive or formalised as it should be in order to show evidence that staff are prepared well for their job and supported while they work in the home. The health and safety of both service users and staff is protected, by ensuring that safe working practices are adhered to. EVIDENCE: Evidence from staff files and discussion with staff revealed that formal documented staff supervision was not taking place, although informal supervision does take place on a regular basis and they feel well supported by senior staff and the manager, all of whom have an “open door” policy for any problems that arise both work related and personal. Induction for new staff members was seen in their files and been completed but is not as comprehensive in its content as is expected for the specialist Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 19 service user group cared for, although dementia is discussed during the first week of induction. This had been a recommendation in the last report. Records to ensure the protection of service users were found to be up-to-date and kept secure when not in use and since the last inspection monthly reports regarding the home, have been received by the Commission, from the provider’s representative. The inspector examined a variety of documents to ensure that the service users and staff’s health and safety were protected; these included periodic electrical testing, gas safety and hoist and lift testing. All were found to be saisfactory. Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x 2 3 3 Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 21 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 2 Regulation 5 Requirement Contracts between the home and the service user for the provision of care, must include a breakdown of the fees payable and by whom. The registered person must confirm in writing, prior to admission, that the home is able to meet the needs of the prospective service user The service user plan (care plan) must be formulated as soon as possible after admission and must identify in detail the action which needs to be taken by both qualified and care staff to ensure that all aspects of the health, personal and social care needs of service users are met. Staff who administer any form of medication must sign the service user’s MAR chart immediately following the administration. Timescale for action June 30th 2005 2. 3 14 June 30th 2005 3. 7 15 May 31st 2005 4. 9 5. 29 13Misuse of Drugs Regs. 1973 NMC Standards of Drug Administr ation 19 May 31st 2005 The required documentation for all members of staff, as stated in Schedule 2 of the Regulations must be available in personnel 30th September 2005 Page 22 Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 files. 6. 36 18 New staff must undertake a comprehensive and documented formal induction procedure focusing on the specialist client group they care for. Documented supervision must tske place for all members of staff at least 6 times a year. 30th September 2005 30th December 2005 7. 36 18 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 3 Good Practice Recommendations As good practice, it is recommended that the preadmission assessment includes all the criteria listed in NMS 3.3, in particular: oral health, foot care, dexterity, history of falls, cultural needs and carer and family involvement and other social contacts/relationships. it is recommended that the dining furnitiure be replaced within the next six months It is recommended as good practice that recruitment application forms have sufficient space to allow a full employment history to be listed. As good practice, notes on recruitment interviews should be made. 2. 3. 4. 5. 19 29 29 Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unity House, The Point Weaver Road, off Whisby Road Lincoln LN6 3QN 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 Martin Hall Nursing Home C53 C04 2543 Martin Hall 222940 220405 Stage 4.doc Version 1.30 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. 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