Inspection on 20/01/06 for Maryville Care Home

This inspection was carried out on 20th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maryville Care Home 01/10/07

Maryville Care Home 21/08/06

Maryville Care Home 24/08/05

Maryville Care Home 16/12/04

Maryville Care Home 10/05/04

Maryville Care Home 17/09/03

Maryville Care Home 16/05/03

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Maryville Care Home The Butts Brentford Middlesex TW8 8BQ Lead Inspector Robert Bond Unannounced Inspection 20th January 2006 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 Maryville Care Home DS0000022899.V273886.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. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maryville Care Home Address The Butts Brentford Middlesex TW8 8BQ 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) 0208 560 7124 The Poor Servants of the Mother of God Sister Margaret O`Connell Care Home 37 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Old age, not falling within of places any other category (0) Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users with Learning Disability between the ages 60 and 65 only may be accommodated. Only the eight bedrooms on the ground floor shall be registered to provide nursing care. Any service user currently accommodated in a bedroom on the ground floor allocated for nursing, who does not actually require nursing care, should be allowed to remain there for as long as their care can be managed appropriately. 24th August 2005 Date of last inspection Brief Description of the Service: Maryville is a Care Home for 37 older people, including older people learning disabilities. Male and female service users are admitted. The home was purpose built and was registered in November 2001. The Registered Provider is the Frances Taylor Foundation. The Frances Taylor Foundation is a Registered charity. The accommodation is on three floors. All the bedrooms are single rooms and have en-suite facilities, which include a shower. Each floor is a separate unit with lounge and dining area and kitchenette available for the service users. In addition there is a well-equipped kitchen where all the meals are provided. There are two passenger lifts and accessibility for wheelchair users at the home. There is a large, well-maintained attractive garden. There is a large well-equipped activity room used by the service users. The home is located within easy access to shops, local amenities and public transport. The Frances Taylor Foundation is a Roman Catholic organisation and the majority of the service users are Catholics. The home accepts service users from other faiths and supports them to attend their place of worship. There is a chapel within the home where services are held six days weekly. The unit on the second floor is for the service users with learning disabilities who are above pensionable age. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the second of the inspection year. The previous inspection assessed the whole of the applicable standards. Therefore this inspection will focus upon assessing whether the home continues to meet certain of the key standards of the Government’s National Minimum Standards (NMS). The inspector assessed the home against 16 Standards and he found that 1 was exceeded, 12 were fully met, but 3 were only partly met. The Inspector made 2 requirements and 1 recommendation. During the inspection, the Inspector met the Manager Designate, toured the home, talked to staff and service users, and examined a number of files, records, policies and procedures. The Inspector noted that the home is planning to create and register a nursing unit on the ground floor. What the service does well: The home is fully occupied, and with the exception of the deputy manager’s post as she has recently been promoted to be the Manager Designate, the home is fully staffed. All the service users spoken to praised the service they received. All the staff spoken to said they were satisfied with the training and support they received. The home is well decorated, furnished and equipped throughout. The grounds are lovely. A Roman Catholic service takes place in the chapel each day. The Manager Designate reported that the home respects the dignity of every service user regardless of their religion, and attempts to meet all their needs. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Maryville Care Home DS0000022899.V273886.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 Maryville Care Home DS0000022899.V273886.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): 1 and 2 The information available to prospective service users is satisfactory. Each service user does not have a written contract/statement of the terms and conditions of their stay within the home. EVIDENCE: NMS1: The Inspector examined the homes Statement of Purpose and Service User Guide. Both were in a user-friendly format. They will have to be revised shortly as the Registered Manager is changing from the individual who is named, and a nursing care unit is planned but not yet referred to in the documentation. NMS2: The Inspector was shown a blank service user’s contract with terms and conditions of their stay. The Inspector examined a service user’s care file and found that although it contained a copy of the contract, the details had not been completed and the document was not signed. Requirement 1. Maryville Care Home DS0000022899.V273886.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, 9, 10 and 11 Individual care plans are satisfactory in their design and content. Medication storage arrangements are satisfactory. Medication records are satisfactory except those for the returning of unused medication to the pharmacist. Services users are treated with respect and privacy. Service users wishes concerning death, funeral arrangements and wills, are recorded in a satisfactory manner. EVIDENCE: NMS7: The Inspector examined a service user’s care plan at random (casetracking). He found that a satisfactory care plan was in place that was based on a pre-admission assessment, and was regularly reviewed. Health information and risk assessments were on the file. NMS9. The Inspector examined the medication storage arrangements and the records kept in one unit of the home. Everything was in order except that no Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 10 records could be located for medication returned to the pharmacist. This was because the record book is handed over to the pharmacist along with the medication to be returned. The pharmacist returns the book at the next visit. The home must maintain a record for inspection. Requirement 2. The Manager designate reported that 6 service users are able to administer their own medication. NMS10: All bedrooms are lockable, and each service user has a lockable drawer. The Inspector observed that service users were being treated with respect and their privacy was considered. No service user that the Inspector spoke to have any concerns or complaints to report. NMS11; The care file that the Inspector examined contained a ‘personal wishes form’ that gave details of the service user’s wishes concerning funeral arrangements, and whether a will had been made. Maryville Care Home DS0000022899.V273886.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 The home provides services that meet the expectations and needs of the service users. EVIDENCE: NMS12: The majority of the service users are Roman Catholic and some are retired ‘sisters’. The home has its own chapel and daily religious service. The Manager Designate reported that other activities included bingo, keep fit, art, and trips to Kew Gardens. The Inspector observed that several service users had left the premises that morning. The Manager Designate said they had gone to a funeral. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 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 the following standard(s): 16 The home’s complaints record is satisfactory EVIDENCE: NMS16: The Inspector examined the home’s complaints file and procedure. No complaints had been received since before the last inspection. The complaints leaflet is user-friendly. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 Service Users live in a safe home that is clean, hygienic, well designed, furnished and equipped. EVIDENCE: The Inspector toured the home and visited several service users bedrooms at their invitation. He found that the home is well designed, well maintained, well furnished and equipped, and it is clean and hygienic. No safety issues were found. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 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 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 home has sufficient staff, other than the deputy manager post being vacant. Sufficient numbers of staff have NVQs in care. In general, recruitment policy and procedures are satisfactory. The home maintains comprehensive training records and formal supervision occurs frequently enough. EVIDENCE: NMS27; The Inspector noted that sufficient staff were on duty. The deputy manager has been recently promoted to Manager (designate). She reported that the home seldom uses agency staff. NMS28: The Manager Designate reported that more than 50 of the care staff have obtained NVQ level 2 or 3 in Care. NMS29: The Inspector examined three staff recruitment files. One had a reference missing but the Manager designate was sure that the reference had been obtained. Two of the application forms did not have the section completed that required next of kin emergency contact details. Recommendation 1. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 15 NMS30. The Inspector examined the home’s training records and a sample of supervision records. Maryville Care Home DS0000022899.V273886.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 and 38 The home is run in a satisfactory manner. The health and safety of service users is promoted. EVIDENCE: NMS33: The Manager Designate explained that she is planning to instigate a service user’s consultative committee. The Inspector examined minutes of staff meetings, housekeepers meetings, and team leader meetings. NMS38: The Inspector observed that each unit of the home now has a book for reporting maintenance issues to the handyman. The Inspector also observed that records of hot water temperatures, fridge and freezer temperatures are kept. Cleaning chemicals are kept locked away. A member of staff acts as Health and Safety Co-ordinator. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 3 Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? no 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 OP2 Regulation 5 (1) (b) Requirement The registered person must provide all service users with the terms and conditions of their accommodation. The registered person must maintain for inspection, a register of medication returned to the pharmacist. Timescale for action 01/03/06 2. OP9 13 (2) 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations Recruitment records should show the applicant’s next of kin emergency contact details and these must be kept up to date. Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Maryville Care Home DS0000022899.V273886.R01.S.doc Version 5.0 Page 20 - 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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