CARE HOMES FOR OLDER PEOPLE
Martins House Jessop Road Stevenage Hertfordshire SG1 7LL Lead Inspector
Mrs Alison Butler Unannounced Inspection 24th November 2005 10:00 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 Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Martins House Address Jessop Road Stevenage Hertfordshire SG1 7LL 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) 01438 351056 01438 741528 Chauncy Housing Association Limited Mr Joseph Hudson Care Home 63 Category(ies) of Dementia - over 65 years of age (63), Old age, registration, with number not falling within any other category (63) of places Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: Martins House is owned and managed by Chauncy Housing Association. Martins House is registered to provide residential support to 63 elderly residents. The home is purpose built three storey setting in a residential area of Stevenage. There is a parade of shops nearby and the town centre is about a mile away. Accommodation is provided in single rooms, although there are facilities to offer shared accommodation if requested. All rooms have an en-suite toilet and washing facilities and there are a number of assisted bathrooms throughout the home. On the ground floor there are two sitting rooms, conservatory, activities room and a large open planned dining room. The main kitchen and storage area is adjacent to the dining room. There are additional small domestic style kitchens on each floor. There is a unit housing eleven frailer residents on the first floor. The floors are linked by two passenger lifts. The home also provides a hairdressing facility. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted with two inspectors, the manager, deputy manager, staff on duty and residents. The majority of the time was spent talking to residents and staff and finding out their views of the service the home provides. Discussions and contact was made with at least 15 residents and 5 staff as well as the manager and the deputy manager. Care and administration records were checked. What the service does well: What has improved since the last inspection?
A number of the areas that had been highlighted for decoration have been completed (see the section on Environment for further details). The number of waking night staff has been increased from two to three. There is also a sleep in manager on call if required. The deputy manager stated that all ancillary staff will have completed training in manual handling by the end of December and they have now all received training in the protection of vulnerable adults. The deputy manager has a matrix in place to ensure staff receive formal supervision at least six times a year.
Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 6 Weight records have been maintained to ensure they monitor any needs that the residents may require. 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. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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 Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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): These standards were not inspected on this occasion. EVIDENCE: See previous report for information on the above key standards. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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, 9 & 10 The quality of the information recorded must be more detailed to ensure the care needs are monitored and reviewed. Residents receive a good quality of care and are supported by experienced and knowledgeable staff. EVIDENCE: Examination of four care plans was carried out and the information was not as detailed as it could be. The deputy manager has recently devised a new care plan format. It is initially being introduced to all new residents as a pilot scheme. The form will then be reviewed and make any changes that is felt necessary will be introduced. It is hoped that it will be then be used for all residents by the end of March 2006. The plans are drawn up with the involvement of the residents and/or family wherever possible. The plans will be further examined at the next inspection to look at progress. Examination of the medication showed that medication was well recorded and the deputy manager follows up any errors. Dates of opening on medication were in place on all liquids and non-dosetted boxes. The mangers must seek further advice on the storage of lactulose, as it should be maintained below 20°C. The bottles of Lactulose within the medication room varied in colour and one was found to be possibly out of date and was a very dark brown in colour.
Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 10 This was to be disposed of as soon as possible. Where residents are self medicating risk assessments must be in place giving details of how to reduce any risks that are identified. For example storage, overdose or missed dose. All residents spoken to were very happy with the care they received and that there privacy and dignity was observed at all times. Residents are encouraged to be as self-caring as is individually possible. Staff were seen to be caring and supportive towards the residents. Comments received from the residents include “get on well with staff” “you can say when things are not right, they get put right and that’s the important thing”. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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, 13, 14 & 15 Autonomy and choice is promoted within the home. Visitors are welcomed and contact is maintained with the local community. Wholesome, balanced and a variety of meals is offered to all residents. EVIDENCE: A craft session was being held in the activities room and the residents were very proud of them and were eager to talk to the inspectors. They had made a number of items for the recently organised Christmas Fair that had raise over £600, which is to help in the purchase of Christmas presents for all the residents. The company is still considering the purchase of a DVD player and large screen television, which will enable a larger number of residents to take part in film afternoons/nights. The activity co-ordinator is starting a memory book for each resident who would like one. There is a section in the new care plan format for social history to be included. A weekly shop is available to the residents, which is run by the Friends of Martins House it sells sweets, chocolates, toiletries and magazines. Residents can request specific items and they can be added to the trolley or purchased as a one off item. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 12 A hairdresser is available in the home. The shower hoses and heads are still waiting to be replaced. The manager stated that the hairdresser is to purchase them and the home will ensure they are fitted appropriately. A calendar of events is displayed within the home. Access to the local community is encouraged and the hiring of transport is available for this. The activities co-ordinator is looking to arrange a trip to the local theatre to see a pantomime. Residents were very complimentary about the food that is offered at Martins House. The menu is a four weekly rolling programme and is changed in line with the seasons. They have some difficulties with a weekend cook and have had to use a local agency to provide the cover. Lunch was observed and this was a very relaxed and unhurried time for the residents. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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 & 18 A complaints procedure is available. Robust recruitment procedures are not in place, leaving residents at possible risk as they are not protected by the homes systems. EVIDENCE: The files for 2 recently employed members of staff were examined. Only 1 reference was found on one file. No terms and conditions or offer letter was available for either staff member giving their start dates, position they are to hold and the number of hours they are required to work. A requirement was made at the last inspection and further failure to comply may lead to further action being taken by the Commission For Social Care Inspection. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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 & 26 The home is clean. Further redecoration and maintenance work is required to ensure that the residents live in a safe, well-maintained and homely environment. EVIDENCE: The home was cleaned to a good standard. A plan was provided to the inspector detailing refurbishment and/or decoration of various areas within the home. Decoration of the corridors has been completed. The middle floor bath and shower room has had the date changed from September 05 till the end of February 2006. The top floor bathroom and shower room is still on schedule to be completed by December 2005. The carpets that are worn and some that have an uneven surface are to be replaced. A plan is to be forwarded to the Commission For Social Care Inspection by end of December 2005. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 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): 27, 29 & 30 Staffing levels are sufficient to meet the need of the residents. Recruitment procedures are not sufficiently robust to protect the residents. EVIDENCE: There has been an increase in the numbers of waking night staff from 2 to 3 since the last inspection. This has provided the residents and staff with greater safety and protection. All ancillary staff have now been provided with protection of vulnerable adults training. All these staff will have completed manual handling training by end of December 2005. The manager should consider having a member of staff that holds a First Aid at Work certificate. Staff records showed that not all the required information was available. See section on Complaints & Protection for further details. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 16 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): 33, 36, 37 & 38 Staff are supervised in their day to day work and a recording process has been introduced. Records are well kept with the exception of the staff files Records are stored appropriately. EVIDENCE: An annual service is to be carried out with the results and an action plan being made available by the end of January 2006. A copy must be forwarded to the Commission For Social Care Inspection on completion. This ensures that standards are reviewed and/or maintained. Regulation 26 visits are carried out. The manager has sent copies to the Commission For Social Care Inspection following the inspection. The manager must ensure that the Commission For Social Care Inspection on a monthly basis receives a copy Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 17 The manager confirmed that a supervision matrix is in place to ensure that all staff receive formal supervision at least six times a year. A detailed premises fire risk assessment has been completed and a copy has been received by Commission For Social Care Inspection to ensure safety and welfare of the residents. A residents room contained two large of oxygen cylinders. These were felt to present a possible hazard as they were not contained within a trolley or were not securely fixed to a point and could become unstable. The deputy manager was unclear as to why there were two in situ and would look into the safety as she thought they were no longer needed. If a resident required oxygen in their room an official sign should be purchased to identify oxygen is present rather than the use of a hand made sign. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 3 2 2 Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 19 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 15 Requirement Care plans must detail all residents assesses and identified needs. This has been brought The manager must seek further advice from the pharmacy regarding the stock and storage of lactulose The manager must ensure that a full risk assessment is in place for all resident who self medicate The manager must ensure that all the relevant information on staff files is available for inspection at all times. This has The manager must ensure that the refurbishment plans continue and be completed to bring all areas up to an acceptable standard. This has been brought
forward from the previous inspection and a new timescale set Timescale for action 31/03/06 forward from the previous inspection and a new timescale set 2 OP9 13 (2) 31/12/05 3 4 OP9 OP18OP29 OP37 12(2) 19(1) & 17(2) 24/11/05 24/11/05 been brought forward from the previous inspection. 5 OP19 23(2)(b) 31/03/06 6 OP33 24 (1) (b) & (2) A report must be completed 31/01/06 following the results of the quality-monitoring questionnaire. This must be made available to all interested parties and a copy
DS0000019460.V266412.R01.S.doc Version 5.0 Page 20 Martins House be forwarded to the Commission For Social Care Inspection. This has been brought forward from the previous inspection and a new timescale set 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 OP12 Good Practice Recommendations The manager should consider purchasing a DVD player and a large screen television to allow a greater number of residents to join in film afternoons/nights. This has been brought forward from the previous inspection 2 3 4 OP12 OP27 OP38 previous inspection. Shower hoses and heads should be replaced in the hairdresser’s room. This has been brought forward from the The manager should investigate in at least one member of staff attending a First Aid at Work training course. This has
been brought forward from the previous inspection The manager should ensure that the oxygen cylinders are securely fastened when in residents rooms to prevent accidents. Martins House DS0000019460.V266412.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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