Inspection on 21/08/06 for Maryville Care Home

This inspection was carried out on 21st August 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 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 20/01/06

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 Mrs Rekha Bhardwa Key Unannounced Inspection 10:10 21st August 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 Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 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.V300827.R01.S.doc Version 5.2 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 Manager Designate (if applicable) Type of registration No. of places registered (if applicable) 0208 560 7124 The Poor Servants of the Mother of God 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.V300827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users with Learning Disability between the ages 60 and 65 only may be accommodated. 20th January 2006 Date of last inspection Brief Description of the Service: Maryville is a Care Home for 37 older people, including older people with learning disabilities and nursing care. 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. The ground floor unit is for service users who require personnel care only. There is a 14 bedded nursing unit on the first floor. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 14 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, staff records financial records, and management records, administration records, maintenance and servicing records were viewed. The Pharmacy Inspector from the CSCI undertook a full pharmacy inspection and a separate record is available. 13 service users and 8 staff spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls were identified in the formulation and review of service user plans. There was a lack of consistency in the maintenance of these records. All assessments in relation to the service users health care needs must be undertaken and regularly reviewed. Shortfalls in medication have been highlighted and should be easy to address. Staff vetting and recruitment procedures must be adhered to and all information required for inspection must be available at the home. Fire drill records must be clearly recorded. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 6 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.V300827.R01.S.doc Version 5.2 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.V300827.R01.S.doc Version 5.2 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 and aspects of 4 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with information about the home. Service users are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: A Statement of Purpose and Service users guide available. The Manager Designate informed the Inspector that this is given to service users when they are first admitted to the home or prospective service users. These were up to date and informative. Contracts and written agreements were available for all service users detailing terms and conditions of residency. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 9 Pre-admission assessments are carried out, and copies of the Social Services needs led assessments were seen in the service user plans viewed. This information provided a clear picture of the service user and their needs. Since the last inspection the home has also been registered to provide nursing care to older people. The nursing unit had been opened on the 12th June 2006. Registered nurses had been employed and this standard will be assessed in detail at the next inspection. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The service user plans did not always identify the service users needs, thus staff were not provided with clear information of how the service users needs are to be met. Assessments including Waterlow, moving and handling, falls, continence, bedrails and nutritional assessments were not always in place, thus potentially placing service users at risk. Staff treat service users with courtesy and respect. EVIDENCE: Service user plans were examined on all three floors. These were inconsistent and did not provide a good picture of the service users needs and how these are to be met. On the ground and second floor units there was evidence of the service user plan being formulated in accordance with Standard 7 of the National Minimum Standards for Older People. There was evidence of monthly reviews. On the nursing unit one Registered Nurse showed the Inspector a sample of draft care plans and assessments that were to be implemented. Two Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 11 service user plans were viewed on the nursing unit. For one service user there was no care plan in place. For all service users there was no risk of falls, nutritional or continence assessments in place. For some service users moving and handling and skin care assessments were in place. For service users who had been assessed as needing a bedrail, no risk assessment or consent were available. Individual risk assessments were available specific to the individual service user. All these areas were discussed with the Manager Designate at the time of the inspection. Monthly weights were not always being undertaken. There were no pressure sores or wounds at the time of the inspection. The GP visits each week and there was evidence of input from other healthcare professionals. The pharmacist Inspector undertook a pharmacy inspection. A separate report is available. Requirements and recommendations from the visit have been incorporated in this report. Staff were seen to converse with and treat service users in a gentle and respectful manner, and service users spoken with said that staff are caring towards them. Bedrooms viewed are personalised and service users are encouraged to bring in personal items, in line with fire safety. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home provides activities to keep the service users active and stimulated. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Information regarding advocacy services is available, thus ensuring service users rights and interests are upheld. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: There is a purpose built Chapel and daily services are held for those who wish to attend. For those service users who are unable to attend the daily service this can be heard via the television in individual bedrooms and lounge areas. The pre-inspection detailed the following activities as taking place: bingo, painting, art, keep fit, outside entertainers, reading, flower arranging and gardening. In addition to this several service users attend activities within the Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 13 community and spend time visiting friends and family. There is a large activities room in the home. Some service users have their own personal computers in their bedrooms. Details of the homes visiting policy are in the service user guide. Visitors were seen visiting throughout the day and visitors can be seen in individual bedrooms or the communal lounge/dining areas. The home has information on advocacy services available. The pre-inspection questionnaire detailed that only one of the service users was managing their own finances. On the second floor staff assist service users to manage their money and separate bank accounts are held. For the majority of service users family or friends manage money on their behalf. Bedrooms viewed were personalised and service users are encouraged to bring in some of their own possessions in line with fire safety. Several service users choose to spend the majority of their time in their individual bedrooms. The menus viewed detailed the meal options available. Service users who spoke with the Inspector confirmed that they had a choice and that they enjoyed the meals. Special dietary needs are catered for. The kitchen was not viewed at this inspection. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that service users and representatives concerns are listened to and acted upon. Staff have received training in adult protection, and therefore service users are safeguarded from abuse. EVIDENCE: The home has in place a complaints procedure. This is also detailed in the service user guide. No complaints have been received since the last inspection and all service users who spoke with the Inspector confirmed that they knew the complaints procedure. Staff had received training in the Protection of Vulnerable Adults (POVA) from the Adult Protection Co-ordinator for Hounslow Social Services. Further training was planned. There have been no POVA issues reported since the last inspection. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home is clean and tidy and the environment is safe for service users. Policies and procedures plus staff training for infection control is in place to safeguard service users from infection. EVIDENCE: The Inspector undertook a tour of the home. A large dining area, kitchenette and two lounge areas are available on each floor. The ground floor has 8 beds for residential care. The first floor is a 14 bedded nursing unit and the second floor is a 15 bedded residential unit for service users with a learning disability. The home has an attractive garden that can be accessed from the ground floor. A patio area is available with garden furniture. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 16 All bedrooms in the home are single and have an en suite to include toilet and wash hand basin facilities. Samples of bedrooms were viewed on each floor and these were personalised and suitably decorated. The furnishings viewed were of good quality. All bedroom doors are lockable, and all beds are height adjustable. Assisted baths area available on each unit. Grab rails and handrails were available throughout the home. Sluice rooms are available on each floor and are located separately from service user areas. The home has two lifts. One, which is a service lift and one, which is a passenger lift. Moving and handling equipment was available on each floor. A call bell system is in place and individual bedrooms have a call bell in place. Several service users have their own telephone within their bedroom. Laundry and kitchen areas are separate from the service user areas. The kitchen was not inspected at this inspection. The laundry was clean and well organised. Information on infection control was available. Gloves, aprons, soap and paper towels were viewed in all bathroom and toilet areas. The home was clean and hygienic. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home was adequately staffed to meet the needs of the service users. Systems for vetting and recruitment practices are in place shortfalls identified do not protect the service users. Staff receive training to enable them to meet the needs of the service users. EVIDENCE: A staff duty rota was available. Staffing levels on the day of the inspection met the needs of the service users. The need to ensure that staffing levels are reviewed in line with service users dependencies was discussed with the Manager Designate. Since the last inspection a full time Deputy Care Manager has been recruited. The home has 19 care staff with certificated NVQ in care level 2. Further NVQ training is planned. Two staff employment records were sampled. One file contained the required information. For the other file viewed there were no references or details of the Nursing and Midwifery Council (NMC) verification. The Manager Designate Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 18 stated that references had been taken up prior to employment and that these were still with the Human Resources department. Evidence that Induction and Foundation Training in line with the Skills for Care core standards was available. New staff undertake an induction programme. There was a staff training and development programme in place, and there was clear evidence that staff had received a minimum of 3 paid training days in the last year. Details of the training undertaken by staff were detailed in the pre-inspection questionnaire. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The Manager Designate has the knowledge and experience to fulfil her role. Systems for quality assurance are in place and service users are able to feedback on the services provided. Systems for health & safety within the home are in place and ensure the safety and protection of staff, service users and visitors. EVIDENCE: The Manager Designate is a first level registered nurse with a Foundation Management Certificate. She has extensive experience for caring for older people. The Manager Designate is in the process of applying to the CSCI for registration. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 20 There is also a Deputy Care Manager who works alongside staff within his role. Several of the staff spoken with said that the Managers are approachable and they do take time to visit the floors and find out what is going on within the home on a day-to-day basis. Regulation 26 Visits are carried out monthly and a written report is also sent to the Commission. Feedback questionnaires are sent to service users, family, friends and representatives. The results of these questionnaires have been collated and sent to the Commission. A sample of servicing and maintenance records were viewed. Generally these were up to date. The fire risk assessment had been updated and regular fire safety checks carried out. Fire records viewed indicated that a fire evacuation had taken place. The Inspector was not clear as to whether this was a drill or an evacuation due to the fire alarms being set off. Each floor has a health and safety book and maintenance book where staff can detail any concerns/issues on their particular floor. The Manager Designate also stated that they have a Health and Safety committee within the home. The home employs a full time maintenance person. Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 21 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X 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 3 3 3 3 3 3 3 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 3 x 3 X X X X 3 Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(2) Timescale for action Reviews of the service user plans 01/10/06 with the service user and/or their representatives must be put into practice. All service users must a service user plan in place. This must be maintained and include all of each individual service users identified needs. It must be updated monthly and when a service users condition changes. Assessments must be carried out for all service users to include nutrition, moving and handling. Waterlow, risk of falling, and continence. These must accurately reflect the service users needs and the action to be taken to meet them. These must be updated as part of the service users plan review and whenever the service users condition changes. Services users weights must be undertaken and recorded in line DS0000022899.V300827.R01.S.doc Requirement 2 OP7 17(1)(a) Schedule 3 01/10/06 3 OP8 17(1)(a) Schedule 3 01/10/06 4 OP8 17(1)(a) Schedule 3 01/10/06 Maryville Care Home Version 5.2 Page 23 with the recorded frequency. 5 OP8 13(4)c Prior to bedrails being used, a risk assessment must be carried out to identify the need for their use and to show that this is the appropriate safety intervention to minimise the risk of harm to the individual. This must be reviewed monthly and whenever the service users condition changes. Agreed consent must be obtained from the service user or their representative. The home must expand its medicines policy to include the management of waste medicines in the home and leave medication The home must not return any medicines or controlled drugs to the community pharmacist The home must be keep written evidence of the current warfarin dose Instruction labels and the MAR should correlate with what is being administered. Adhesive labels should not be used on the MAR, as they do not provide a permanent record of administration. The oxygen cylinder must be checked weekly and an appropriate warning sign placed on the door Staff records must contain the information as required by Schedule 2 of the Care Homes Regulations 2001. Fire records must clearly detail when fire drill training has taken place. 01/10/06 6 OP9 13 (2) 01/10/06 7 8 9 OP9 OP9 OP9 13(2) 13(2) 13(2) 01/09/06 01/09/06 01/09/06 10 OP9 13(2) 01/09/06 11 OP29 Schedule 2, 19 23(4) 01/10/06 12 OP38 01/10/06 Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 24 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 Maryville Care Home DS0000022899.V300827.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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.V300827.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!