Inspection on 31/05/06 for Maryam Rest Home

This inspection was carried out on 31st May 2006.

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

Maryam Rest Home 24/09/08

Maryam Rest Home 10/10/06

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 10:00 31st May 2006 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.V292858.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.V292858.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.V292858.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. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection carried out under Inspecting for Better Lives. An approach that is introducing proportionate inspection activity based on the level of risk identified at the home. All services will have at least one key inspection between April 2006 and June 2007. Due to the significant number and nature of requirements outstanding from previous inspections this home was rated as poor. Following this inspection sufficient improvements have to be made for it to be assessed as having adequate levels of risk. The visit to the home was carried out by two inspectors who each took 6 hours to gather information and speak to the residents before giving the manager detailed feedback. Prior to the inspection visit, 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. In addition surveys were left at the home for completion by residents and their relatives. What the service does well: What has improved since the last inspection? The manager has made very good progress in developing and maintaining care plans for residents. The care plans are supported by comprehensive assessments and include risk assessments. The residents’ wishes in relation to care if they become ill or are dying have been identified and recorded. The manager is attending more training and there is evidence of this being Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 6 translated into practice – for example purchase of more arts and crafts materials. Risk assessments for the environment have been introduced. The manager said that she has help from her husband and sister in running the home. This will give her more time to manage and administer the home. 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. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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): 1, 2, 3, 4 and 6 Prospective residents and their representatives do not have all the information they need. They have their needs assessed but do not all have a contract that clearly tells them about the service they will receive EVIDENCE: A statement of purpose has now been drafted which covers the areas required. Minor changes are needed so that service users know about the sizes of rooms and know about who works at the home. There is a brochure that is used as a service user guide. This will be looked at at the next inspection. An assessment is now in place for all service users. A statement of terms and conditions (contract) was seen in place for 2 out of the 4 service users. This tells service users about fees including what the fees don’t cover. The contract also tells service users that places are offered on a trial basis until a review is carried out. The circumstances under which the Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 9 contract may be terminated are also outlined such as when a service user’s needs can no longer be met at the home. The manager has now undertaken training on diabetes care. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 and 11 Some work is needed to ensure that the health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service user care plans have been in place since March 2006. Monthly reviews were carried out on all care plans in April and May. The manager plans to carry out a three-monthly review involving family members. A monthly review with family is planned for one service user whose needs are changing rapidly. This will be 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.V292858.R01.S.doc Version 5.1 Page 11 • social history. 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 the manager should make sure that the care plans are both signed and dated. Daily recording is not taking place. The manager has set up a book for each service user and should ensure that a record is kept which will help monitor health changes, changes in appetite, participation in activities. Service users spoke about having hearing tests, chiropodists’ visits and having the doctor visit etc. A form has been developed by the manager to record such visits and this should be used. Medication records were looked at and found to be fully completed. Medication is stored appropriately. All personal care is provided in the privacy of service user’s own bedrooms. Service users said that they are treated very well, “she can’t do enough for us” A service user was reminded about using the bathroom in a way that maintained her dignity. This is good practice. 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.V292858.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities must meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. Recordkeeping needs improvement EVIDENCE: A programme of activities is displayed in the reception area. This needs updating to reflect activities actually taking place within the home. A new programme is being drafted and the manager has been buying craft and activity materials based on suggestions from the activities coordinator’s course she is currently undertaking. We talked about activities meeting the needs, abilities and preferences of the service users who live at the home. The manager talked about a communion service held at the home at Christmas and Easter as one of the residents was no longer able to go to church. Residents choose whether or not they want to participate in such activities Another resident had transport difficulties getting to the church and the manager worked with the family to agree an alternative. She is now collected and accompanied to church by a friend. The home can demonstrate it is meeting the religious and spiritual needs of its residents. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 13 A hairdresser visits the home weekly on Wednesdays. All residents have regular visits by family members. One resident said she had been out visiting her family the day before. 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. One resident was having breakfast at 10am and others had their breakfast later. Drinks were made available throughout the day Lunch was served shortly after 1pm and consisted of quiche and seasonal vegetables; the dessert served was apple pie and custard. Service users said the “the food is always good” meat is always cooked properly and “ if we don’t like it all we have to do is ask for something else”. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 the following standard(s): 16, 17 and 18 Current policies procedures and training do not give residents’ the protection they need. EVIDENCE: The home’s complaints procedure is prominently displayed in the reception area. However, the manager needs to introduce a system for recording complaints received, any investigations and outcomes. Letters were seen that confirmed that an application has been made to allow residents to participate in elections. The manager is not an appointee for any of the residents and they all take responsibility for managing their own finances with support from families. The manager has undertaken adult protection training and the adult protection policy is displayed in the office. This outlines procedures for contacting the local authority adult protection unit. The manager was reminded that all persons responsible for caring for residents must have training in adult protection. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 the following standard(s): 19, 20 and 26 The home is well maintained, decorated and furnished and provides a comfortable environment, inside and outside. There is good attention to hygiene and cleanliness throughout. The residents benefit from a clean 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. There is a call bell system in place and this was tested by one inspector and found to be working. All commode pans are sterilised daily and the whole commode is washed down weekly. Residents’ clothing appeared to be very well-cared for. There is no sluice cycle on the washing machine and this facility may need to be reconsidered as residents’ needs change. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 16 Residents’ toiletries are kept in their own bedrooms. Hand soap and shampoo used by the family should be removed from the bathroom to comply with good practice in infection control. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 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 Residents could be at risk if care continues to be provided solely by the manager. EVIDENCE: The pre-inspection questionnaire completed by the manager states that her husband also works at the home. The manager confirmed that he works at the home, assisting with meals, cleaning and handyperson tasks. He is left in charge if the manager needs to leave the premises. This staff member’s role needs to be made clear with agreed hours and responsibilities. A food hygiene training certificate was seen but there was no other record of training or supervision for this member of staff. The manager said a Criminal Records Bureau check had been undertaken. She was asked to submit evidence of checks for any person caring for or having access to the residents. This should also include other family members. Staff employed must have a programme of training including induction and receive regular supervision. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 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 and 38 Health and safety practice needs improvement to make sure residents are safe. EVIDENCE: The manager continues to carry out all personal care, cooking and recordkeeping at the home. She has undertaken some training and is currently undertaking an activities coordinator’s course. There is informal consultation with residents but this is not recorded. Recordkeeping 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. All residents’ finances are handled by their relatives; the manager should make sure that receipts and recordkeeping are clear. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 19 An environmental health report made requirements about checking fridge freezer temperatures and checking the temperature of prepared food. The checking of food temperatures has yet to be started but records were seen confirming fridge-freezer temperature checks are now being done. 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 the attached risks must be assessed. Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 2 28 N/A 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 2 Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 21 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 OP1 Regulation 4 Requirement The registered person must ensure that there is an up-todate statement of purpose available and include details of the room sizes and staff who work at the home. The registered person must ensure service users are issued with a statement of terms and conditions. (Timescales of 31st March, 31st August 2005 and 31st December 2005, 30TH April 2006 not met) The registered person must ensure each service user has an individual service user plan. This must include daily recording to enable health and other needs to be monitored (Timescales of October 2004, March 2005 & 31st August 2005, 31st January 2006 and 30th April 2006 not met) The registered person must record meals served. (Timescales of 31st January 2006 DS0000001176.V292858.R01.S.doc Timescale for action 31/07/06 2. OP2 5 30/09/06 3. OP7 15 31/07/06 4. OP15 17 31/07/06 Maryam Rest Home Version 5.1 Page 22 and 30th April 2006 not met) 5. OP16 17(2) The registered person must make sure a record is kept of all complaints made and this must include details of investigation and any action taken. The registered person must make sure that there are enough people working at the home to meet the needs of service users and to ensure effective management of the home (Timescales of 31st January 2006 and 30th April 2006 not met) The registered person must make sure that CRB and POVA checks are carried out in respect of all persons working at the home. The registered provider must ensure that induction; training and supervision are put in place for any staff employed at the home. The registered provider must make sure information relating to service users is recorded. (Timescales of 31st January 2006 not met) The registered person must complete a specific risk assessment for the hot water outlets in bedrooms. (Timescales of March 2004, December 2005, March 2005 & July 2005 and January 2006 and 30th April 2006 not met) 30/09/06 6. OP27OP31 18 31/07/06 7. OP29 19 31/08/06 8. OP36 18 31/07/06 9. OP37 17 30/09/06 10. OP38 13 31/07/06 Maryam Rest Home DS0000001176.V292858.R01.S.doc Version 5.1 Page 23 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 OP33 Good Practice Recommendations The registered person should ensure service users’ views are recorded. The quality assurance system should be developed further to include collation of information gathered and sharing of outcomes with key stakeholders including the Commission. Maryam Rest Home DS0000001176.V292858.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.V292858.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. 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