Inspection on 10/10/06 for Maryam Rest Home

This inspection was carried out on 10th October 2006.

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

Maryam Rest Home 24/09/08

Maryam Rest Home 31/05/06

Maryam Rest Home 21/10/05

Maryam Rest Home 01/06/05

Maryam Rest Home 14/02/05

Maryam Rest Home 27/07/04

Maryam Rest Home 28/05/03

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Maryam Rest Home 4 Hazelhurst Road Bradford West Yorks BD9 6BJ Lead Inspector Sughra Nazir Unannounced Inspection 11:00 10 October 2006 th 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 Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maryam Rest Home Address 4 Hazelhurst Road Bradford West Yorks BD9 6BJ 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) 01274 820377 01274 544014 N/A Mrs Maryam Afzal Mrs Maryam Afzal Care Home 4 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (4) Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2005 Brief Description of the Service: Maryam Rest Home is a private home situated in a quiet residential area in Chellow Dene, Bradford. There is a small area for parking directly in front of the home. Attractive and well-maintained gardens are to the rear of the property. The home is registered to provide personal care for up to four older people. The accommodation consists of four single bedrooms, which are located on the first floor. These can be accessed by a stair lift. The home has a large lounge and separate dining room. The philosophy of the home is to provide a family based lifestyle in a homely environment, where service users are encouraged to maintain independence. Fees range from £358.75-£372.75 and are based upon Social Services rates plus a top-up fee. Extras are documented in the Statement of terms and conditions. All previous reports are available for inspection. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) will be inspecting homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between April 2006 and June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All the key National Minimum Standards are assessed and evidence gathered is used to assess outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific areas and are known as random inspections. This was the second key inspection of this home for the 2006 to 2007 period. Due to the number and nature of requirements outstanding from previous inspections the indicative quality rating for this home was adequate. The visit to the home was carried out by one inspector who took 5 hours to gather information by looking at files and speaking to the residents, the manager and staff before giving the manager detailed feedback. In April a pre-inspection questionnaire was sent out to the manager for completion. This was returned and the information has been used to inform the visit. Since the last inspection 4 survey cards were received from relatives. No specific comments were made and all the cards gave positive responses to the questions asked. Any comments made by residents during the inspection are included in the report. During the visit one resident said the manager “works very hard and can’t do enough for us.” What the service does well: The home is very well-maintained with a high standard of cleanliness and décor. The external appearance of the building is attractive and welcoming. The front garden has been extensively landscaped and now provides an attractive seating terrace with views over a fountain. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 6 Residents and relatives describe care as excellent. The philosophy of the home is very family-centred and residents received care in a warm and friendly atmosphere. The home can demonstrate competence in responding to equality and diversity issues. This is by identifying and delivering activities that meet spiritual needs, offering a diet that meets cultural needs, and making alternative arrangements for residents to overcome physical difficulties What has improved since the last inspection? What they could do better: The home has a quality assurance survey that has been used to obtain residents/relatives views. These have been filed and the manager should now introduce a system for feedback actions to residents, relatives and the Commission. This will mean that residents and their relatives know that their views have been listened to. The home employs one member of staff – the manager’s husband and informal supervision and contact takes place daily. The manager has agreed to record any formal supervision sessions. This will mean that residents know that any Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 7 staff training needs have been identified and that information about the care they need is made available to all staff. 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. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 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 the following standard(s): 1, 2 and 3 (and 6) (Standard 6 does not apply) The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. Residents now have access to all the information they need to make decisions about their stay. (The home does not provide intermediate care.) EVIDENCE: A revised Statement of purpose was sent to the Commission on 29th June 2006. This now covers sizes of rooms and provides details of staff employed in the home. There is a brochure that is used as a service user guide. An assessment is now in place for all residents. One resident has moved in since the last inspection and her file contains a single assessment record as well as a comprehensive assessment. A statement of terms and conditions (contract) can now be seen for all residents. This tells residents about fees including what the fees don’t cover. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 10 The contract also tells residents that places are offered on a trial basis until a review is carried out. The circumstances under which the contract may be terminated are also outlined such as when a resident’s needs can no longer be met at the home. Maryam Rest Home does not provide intermediate care. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 11 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 and 11 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. There are good records in place and this means that residents can be sure that their needs have been identified and will be met. EVIDENCE: Service user care plans have been in place since March 2006. Monthly reviews have been carried out on all care plans. Three-monthly reviews have also been taking place involving family members. This is good practice. All 4 care plans were looked at. They all included • A social services assessment • the home’s own assessment • details of next of kin and arrangements for death and dying • assessment using Barthel scoring • waterlow assessment • nutritional assessment • moving and handling risk assessment • falls risk assessment Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 12 • • falls diary social history. The manager has also introduced oral health assessments based on training she has attended since the last inspection. The social histories are comprehensive and give a lot of historical information about service users lives. This helps the manager deliver person-centred care and is good practice. All care plans have been agreed with relatives and have been dated. Daily recording is not taking place. After some discussion it was agreed that due to the size of the home the manager would complete a weekly record for each resident that would help her to monitor health changes, changes in appetite, participation in activities. By the end of the inspection visit the manager had put in place a form for weekly recording. There is good record keeping of other professionals’ visits. All chiropodist visits are recorded. GP visits are recorded by the GP and include any agreed action. There is a medication change sheet that lists any medication changed or stopped. Medication records were looked at and showed that recordkeeping is neat accurate and up-to-date. Medication is stored appropriately. A plan was seen which showed dates agreed by the manager with the pharmacy for collection of prescriptions and delivery of medication. All personal care is provided in the privacy of residents’ own bedrooms or in the bathroom. Residents said the manager “never stops and can’t do enough for us.” The wishes of service users in relation to illness, end of life care and death are recorded in some detail on their files. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 13 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 and 15 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. Residents are able to follow chosen lifestyles and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirements and choice. EVIDENCE: A programme of activities is displayed in the reception area. The manager has bought a large stock of arts and crafts materials based on suggestions from the activities coordinator’s course she has completed. She has spoken to residents and now accepts that activities need to reflect residents’ preferences. On one resident’s files there was a record of conversation about TV channel choices. A communion service is held at the home at Christmas and Easter, as one of the residents is no longer able to go to church. Another resident continues to attend church after problems with transport were discussed and agreed with a Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 14 relative. The home can demonstrate that it is meeting the religious and spiritual needs of its residents. One resident attends a day centre. Another has talking books from the library. Residents choose whether or not they want to participate in such activities A hairdresser visits the home weekly on Wednesdays. All residents have regular visits by family members. On the day of the visit to the home it was noted that at 10.30am there were two residents in the lounge. One other resident was still in bed and one was receiving help with personal care upstairs. This shows that there is flexibility about routines. The manager said that she helped residents select clothing they would like to wear the next day and this is left out for the next morning. Residents can choose when they get up and when they go to bed. They can choose whether they want to participate in any activities. Drinks were made available throughout the day Lunch was served shortly after 1pm and consisted of quiche and seasonal vegetables. Portions sizes were good. One resident asked for gravy and this was brought to the table. There was a range of drinks on the table including cordial, diluted juice and tea. Residents helped themselves to seasoning. Choice is offered and individual preferences are accommodated for example one resident enjoys meals that reflect time spent abroad. One resident needed some help with her meal and she was then encouraged to continuing eating by herself. This maintains independence. The home operates a four weekly menu system and it was agreed that this would serve as a record of meals served as long as any changes were recorded. The manager also said she would record the diet and fluid intake of any resident who was unwell. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. Residents know how to complain and policies and procedures are in place to keep them safe. EVIDENCE: The home’s complaints procedure is prominently displayed in the reception area. The manager has introduced and is now using a form to record complaints received and action taken. One entry showed that she had responded to a complaint about TV channels and taken action. The entry was also signed by the resident’s relative to show that they were aware. This is good practice. The home has not had any serious complaints. The manager and staff member have both had adult protection training and the adult protection policy is displayed in the office. This outlines procedures for contacting the local authority adult protection unit. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 16 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, 20, 23, 24, 25 and 26 The quality in this outcome area is excellent. This judgement has been based on available evidence including a visit to this service. The home is well maintained, decorated and furnished to a high standard. There is very good attention to hygiene and cleanliness throughout. The residents’ live in a clean comfortable and safe environment. EVIDENCE: All areas of the home seen were found to be very clean and free from odours. Bedrooms vary in size, are well decorated and very clean. The bedrooms seen were pleasantly furnished with a good array of personal items. Residents’ toiletries are kept in their own bedrooms. There is a call bell system in place. All commode pans are sterilised daily and the whole commode is washed down weekly. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 17 Residents’ clothing appeared to be very well cared for. All items are washed dried and ironed with care. There is no sluice cycle on the washing machine and this facility may need to be reconsidered as residents’ needs change. Both the manager and her husband have had training on infection control. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 18 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, 28, 29 and 30 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. Residents know that they will be looked after by staff who can meet their needs. EVIDENCE: Following the last inspection the manager sent in a rota showing hours worked by her husband. She has also informed the Commission that her sister provides additional emergency cover. It was agreed that an NVQ (National Vocational Qualification) at level 2 was not needed for the manager’s husband who is the only additional member of staff employed at the home. This is because he has a master’s level qualification. He can demonstrate that he is able to meet needs as he has undertaken a 3day induction programme and training on • Care values • Dementia and challenging behaviour • Medication • First aid • Adult protection • Food hygiene • Moving and handling Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 19 • • • Infection control Fire safety Health and safety. All this training has taken place since the last inspection. Both this staff member and the manager’s sister have had POVA and CRB checks. These are kept in files along with their training records. It was agreed that the Commission would accept that there was no formal application form or references on file. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. This is a small home and the manager’s focus is on delivering personal care. Management practice is improving. EVIDENCE: The manager continues to carry out all personal care at the home. She now has some help with cooking and recordkeeping at the home. Since the last inspection she has completed an activities coordinator’s course and training on oral health. There is informal consultation with residents and record keeping is improving. A formal quality assurance system has now been introduced. This needs to be improved to give residents and others feedback on its findings and outcomes. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 21 All residents’ finances are handled by their relatives; the manager should make sure that receipts and recordkeeping are clear. Due to the size of the home the manager has ongoing discussions with her husband about care needs. After some discussion the manager agreed that she would record formally conversations about training and would ensure that a meeting of this nature takes place at least once every 2 months. The manager talked about difficulties putting into place environmental health requirements about checking fridge freezer temperatures and checking the temperature of prepared food. Records were seen confirming fridge-freezer temperature checks are now being done. At the last inspection evidence was seen of other checks /testing carried out including. • • • • Gas boiler service Emergency lighting checks, smoke alarm tests, fridge/freezer temperature tests. Hoist service record Fire extinguishers service Risk assessments have been introduced for environmental hazards, equipment and chemicals kept in the home. Supporting information from product manufacturers was seen on file. This is good practice. Hot water outlets in individual bedrooms do not have thermostatic controls and risk assessments have been carried out. All action such as the placing of signs alerting residents to the risks have been taken. Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 23 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 The registered person must ensure that records are kept to help monitor health changes, nutritional intake and activities undertaken. The registered person must make sure that the results of the quality assurance surveys are shared with residents, relatives and the Commission Formal supervision must take place at least 6 times a year and be recorded. Timescale for action 31/12/06 2 OP33 24 30/06/07 3 OP36 18 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Maryam Rest Home DS0000001176.V324979.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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