Inspection on 18/08/05 for Mary Chapman Court

This inspection was carried out on 18th August 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

Mary Chapman Court 24/10/08

Mary Chapman Court 28/06/07

Mary Chapman Court 05/07/06

Mary Chapman Court 01/04/05

Mary Chapman Court 09/11/04

Mary Chapman Court 20/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mary Chapman Court Mary Chapman Close Dussindale Norwich NR7 0UD Lead Inspector Susan Golphin Announced 18 August 2005, 09:00 th 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. Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mary Chapman Court Address Mary Chapman Close, Dussindale, Norwich, Norfolk. NR7 0UD. 01603 701188 01603 504906 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) Alphacare Services (UK) Ltd manager in post -application to register not yet submitted Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to thirty four (34) Older People, not falling into any other category may be accommodated. Date of last inspection 19th April 2005 Brief Description of the Service: Purpose built in 1997, Mary Chapman Court is located in a residential area on the outskirts of Norwich in Thorpe St Andrew. The home can accommodate 34 older people in 28 single (26 with en-suite) and three double rooms (1 with en-suite). The accommodation is on the ground and first floors. The first floor can be accessed by passenger lift. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The home is supported by the local GP practices, and other health professionals. Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced at short notice as a result of concerns raised about care practice and staffing levels. The inspection was carried out by the lead inspector and with the cooperation of the management of the home and the directors of the company. The inspection process was conducted between 9am and 6.30pm and included a brief tour of the premises, discussions with staff, residents, visitors and extensive discussions with the manager of the home Mrs Cherie Steptoe and Mrs Yvonne Delph Nurse Care Manager for Alpha Care ( UK) Ltd. Some sample documents were also seen relating to staff rota’s care plans, medication practice and policy. Issues raised by the relatives of one resident were being addressed by the management of the home just prior to the inspection. It was acknowledged that one element of the complaint was upheld and attended to directly by the manager and directors. Feedback on the inspection was given to the manager Mrs Cherie Steptoe and the Nurse Care Manager Mrs Yvonne Delph. What the service does well: What has improved since the last inspection? The manager has been in post since April 5 2005 and a number of significant changes have been made in that time including meeting three out of the five requirements made at the last inspection carried out on 1st April 2005. The noticeable improvements are -: Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 6 • Better communication systems within the home and with other healthcare professionals. There have been two full staff meetings in the last six months and regular meetings with the District Nursing Services to ensure that residents healthcare needs are being monitored and recorded as part of the review process. Communications book established to record all professional visits record any immediate changes in need or care support. and • • A working protocol has been established with the district nursing staff based at the surgeries used by the home, to promote a better understanding of the working roles for both nurses and care staff. A new post is being created , adverts for the post have been placed locally for a Head of Care. The person appointed will be directly responsible for supervising the care practices and care input on a daily basis and supporting the manager. Mandatory training and sessions relevant to care of older people are in place. A recent audit carried out by the Nurse Care Manager showed an overall outcome of 3 sessions of training relevant to work was provided to all staff within 6-8 weeks of their employment. Training sessions covering adult abuse awareness, care planningpractice and principles and values now form part of the induction training for all staff. • • • What they could do better: • • Review and update the homes service users guide to reflect the change of manager and managerial style. Provide additional administrative support to manager until the newly created post of head of care is in place to allow the manager time to address staffing matters and management and care practice supervision. There is an urgent need for the directors of the company and the management to look at how they address complaints and communicate with other health care professionals, staff, residents and relatives when dealing with issues and concerns to ensure that the approach is one of openness and with a clear aim to resolve matters through a positive but amicable process. The process should also include a review of the complaints procedure to establish why some complaints are not raised directly with the management in the first instance. I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 7 • Mary Chapman Court • • Promote and improve the NVQ training opportunities for staff at all levels. Review the recruitment processes to ensure the suitability and appropriateness of the applicants to promote stability and commitment to the staff team. Review the way in which staff respond to call bells and agree on a working protocol that all staff understand and comply with and ensure that all calls are responded to promptly. One resident said that the staff are very good but always seem busy and sometimes they take ‘quite a time’ to answer the call bell. Review the time medication is administered at meal times to assess whether small time changes can be made to allow for additional care staff availability and flexibility. Review the current activities for residents and introduce positive social stimulation on an individual as well as group basis, which will allow staff to proactively plan individual activities to alleviate boredom and isolation. Two residents said that they enjoy the group activities but would like to do other things which have a personal interest to stop them feeling bored and isolated. Review the current healthcare needs of the residents to ensure that their assessed needs are continuing to be met by the home and that the reviews are updated in each plan of care. The review should also be used to ensure that there are sufficient numbers of staff on duty at crucial and recognised social times of the day to meet resident’s needs. Re-establish the formal supervision of all staff which should also include the monitoring of staff skills, competency and performance to ensure that the service delivery is robust and consistent and of a good standard. A review of the medication policy and procedure should be carried out to ensure the policy incorporates clear guidance on individual and generic risk assessments and covert practice. • • • • • • 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. Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 8 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 Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 9 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 The homes service user guide is available to prospective residents, but is out of date and therefore not providing clear information about the service. EVIDENCE: The service user guide for the home has not been updated recently to include the changes in staff personnel including the appointment of the manager in April 2005. Residents and relatives and visitors need to be able to access relevant and up to date information about the service provision. (See requirement) Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 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) 7,9 The care planning process is in place but has not been consistently reviewed to ensure the needs of the resident’s are effectively being met. The home’s procedures and systems for the administration of medication are in place, but do not include guidance for covert administration and or risk assessments for individual management and administration. EVIDENCE: The manager has begun the task of reviewing all the current residents care plans but has only completed a small number, due to other work commitments. It is essential that this piece of work is completed as soon as possible. ( see requirement) During the course of the inspection the administration of medication for one resident was the subject of debate and raised issues around the breaking up or crushing of medication to make the medication easier to swallow. It was recognised that the practice needs to be reviewed and that risk assessments be completed for residents where standard administration is not appropriate or applicable. ( see requirement) Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 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 standard(s) 12 Some areas of resident’s lifestyles within the confines of the home match expectations and preference, however not all residents individual recreational interests and needs are being met. EVIDENCE: The care documents reflect resident’s social and recreational interests but do not say how the home will meet individual expectations. Group activities and entertainments take place on a regular basis. A review of resident’s individual interests should be carried out to promote stimulating and interesting activities to alleviate boredom and isolation. One member of staff said that they try to spend time with individual residents just to chat and take an interest in what they are doing. Other times he will read the daily newspaper to one resident who also likes to talk about the years he spent in the desert during the war. (see requirement) Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 12 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 complaints procedure for the home is in place and can be accessed by relatives and residents. EVIDENCE: Residents said that they would discuss any worries or concerns with the manager or with staff. The Nurse Care Manager audits any concerns and complaints each month and comments are included in the regulation 26 reports which are submitted to the CSCI. The company and the management are aware that some issues and concerns are raised with outside agencies without reference to the company and management and will be reviewing the current policy and information available to ensure that the procedure encourages openness and co-operation. ( see requirement) Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 13 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) This standard not assessed on this occasion. EVIDENCE: Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 14 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) 27,30 Staff have a good understanding of residents needs but there is some instability within the staff group which affects the overall consistency of care at times. Systems for providing and promoting staff training are in place and being developed in relation to the needs of older people. EVIDENCE: The staff group are committed and caring about what they do and understand their own roles well. They also acknowledge their own restrictions and short comings because at times there are not enough staff at crucial times of the day when demand is highest or for them to provide social and emotional support on a flexible basis. The manager acknowledges that due to the turnover of staff in recent months it has been necessary to concentrate on recruiting and inducting new staff mainly from abroad , and this has limited the time available to input and review staffing levels in relation to changing needs of residents. At the previous inspection it was required that the management team review care practice and performance in relation to the care needs of residents especially those with a higher dependency on staff . This requirement has not been met within the timescale and will be taken forward at this inspection. (See requirement) Since her appointment Cherie Steptoe has worked consistently at developing both the induction and foundation training for staff and producing Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 15 handouts and training material for use in the home. Staff acknowledge the input of training and also commented on the ease at which they can access the manager for advice and practice guidance. Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 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 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 There is no consistent supervision process in place to provide staff with the support and guidance to evaluate standard of care and promote best practice. EVIDENCE: The formal supervision of the staff group is not in place and needs to be reestablished so that routine care practices and standards of service can be monitored and staff competency and ability can be evaluated and developed. ( see requirement). Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 17 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 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x 2 x x Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 18 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 1 Regulation 6(a&b) Timescale for action The registered providers are immediate required to review the current and by 30 service users guide to ensure the September information available is up to 2005. date and consistent with the service provided. The registered providers must immediate ensure that the plan of care is and by reviewed regularly and continues October to meet the care needs of each 31st 2005. resident. residents or their representatives should be involved in the review. The registered providers must immediate review the medication policy for and the home to ensure the ongoing. procedure includes guidance on individual risk assessments The registered providers must immediate implement a process for and by assessing the social and October emotional needs of the residents 31st 2005. in a planned way. Social stimulation should be offered and provided by staff both individually and in group form to promote meanigful activities and interests. The registered providers must immediate review the current complaints and by procedure for the home to October Version 1.40 Page 19 Requirement 2. 7 15b 3. 9 13(2) 4. 12 16(2) i m 5. 16 22 Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc 6. 27 18 (1&2) 7. 36 18(2) ensure that relatives and residents are reassured and confident that their complaints will be listeded to and acted upon in a spirit of openess and cooperation. The registered providers must review the current staffing levels and the skills and abilities of the care staff to ensure that the residents care needs are met. REPEATED REQUIREMENT The registered providers must ensure the formal supervision arrangements for all staff is reintroduced to monitor and maintain professional development and competency. 31st 2005. immediate and by October 31st 2005. Immediate and by 31st October 2005. 8. 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 none. Good Practice Recommendations Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 Mary Chapman Court I55 s44397 Mary Chapman Court v244732 UN 180805 Stage 4.doc Version 1.40 Page 21 - 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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