Inspection on 24/08/05 for Maryville Care Home

This inspection was carried out on 24th August 2005.

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 20/01/06

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 Jean Bovell Unannounced 24th August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Maryville Care Home Address The Butts, Brentford, Middlesex, TW8 8BQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 560 7124 The Poor Servants of the Mother of God Bridget Stephanou 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 G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2004 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 G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 24th August 2005. It commenced at 10.55 am and ended at 4.20 pm. The Registered Manager, Deputy Manager and six care support workers were on duty. The Inspector spoke to ten service users and four members of the care staff. A tour of the building and its surrounding gardens was undertaken. The home’s records and documents were examined. The Registered Manager and Deputy Manager were co-operative and assisted the Inspector throughout the inspection. Overall the home was organised and properly maintained. There was a calm and homely atmosphere and the service users appeared comfortable within their environment. What the service does well: The home does not employ agency staff and has maintained a permanent staff group. All members of the care staff have received appropriate training for meeting the needs of the service users. A high standard of care is provided to the service users. They receive choice in relation to daily living routines and personal preferences. Their health, welfare and safety are being protected within the home. Service users were observed to relate in a friendly manner with the care staff who responded sensitively and appropriately to their needs. The service users appeared content and well cared for. All records and documents seen were up-to-date. The home was hygienically clean and well maintained throughout. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5 and 6. The home’s policy and procedures relating to the assessment and admission of prospective new service users were satisfactory. EVIDENCE: The home’s policy and procedures on assessment and admissions were in place. The Registered Manager confirmed that social workers, relatives and friends participated in the assessment process for ensuring the home’s suitability in meeting the needs of a new service user. Medical Professionals such as District Nurses, Psycho Geriatricians, Physiotherapists and Occupational Therapists were also involved, where appropriate. Prospective new service users were invited to visit the home prior to admission. They were initially placed on a two-week trial period after which a review would be held. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 9 The records indicated that new service users were required to sign a written contract/statement of purpose at the point of admission. The home does not admit service users who require intermediate care. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11. The health and personal care needs of the service users are being satisfactorily met and their privacy and dignity are respected. EVIDENCE: The home’s policy and procedures relating to the storage and administration of medication were satisfactory. The Inspector was advised that the care support staff had all received medication training. Medication was safely stored and properly administered and documented. Disposable medication was returned to the Pharmacist. The Registered Manager confirmed that several service users self administered their medication. The Inspector examined a number of service users care plans. These contained separate assessments in relation to service users’ health care needs, personal care and social interests. Appropriate risk assessments had also been undertaken. All care plans and risk assessments seen were regularly reviewed. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 11 The Registered Manager reported that many of the service users were independent in accessing medical services such as Dentists, GPs or Chiropodists. However, these services were also provided at the home where necessary. One service user independently kept an appointment with an Audiologist at the time of the inspection. The service users who spoke to the Inspector confirmed that their privacy and dignity were respected at the home. The home’s policy and procedures regarding the death of a service user was in place and the records indicated that personal wishes or requests were established during the initial assessment process. The Inspector was informed that these matters are handled with sensitivity and respect and that a member of staff had been attending the funeral of a recently deceased service user at the time of the inspection. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15. Service users are able to exercise choice at the home. Their spiritual and social needs are being met and varied and wholesome meals are provided. EVIDENCE: Although the majority of the service users are Roman Catholics, members of other religious faiths are also resident at the home. A Catholic Mass was held at the home during the inspection and the Inspector was advised that this occurred on a daily basis. Support was, however, offered to service users who wished to attend Church Services of alternative faiths. There was an Activities Room at the home in which there was a computer, keyboard, television and various books. The Inspector was informed that indoor activities included bingo, keep-fit and art. A variety of service users drawings and paintings were displayed on the walls. Service users were observed arranging flowers, tending potted plants, assisting around a dining area and resting or reading in their bedrooms. Others sat in groups watching television or chatting. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 13 Outdoor activities such as outings, shopping trips, visits to friends or the theatre also occurred. A number of service users attended colleges or day centres. The home had an open policy regarding visitors and relatives and friends are encouraged to maintain contact. Service users chose what to wear, when to go to bed at night or get up in the morning. They were able to go and come as they wished and were observed to move freely and comfortably around the home. Three cooks were employed at the home and it was indicated on the menu that varied and nutritious meals were provided. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 standard(s) 16,17 and 18. The home’s policy and procedures in relation to complaints were satisfactory. EVIDENCE: The home’s policy and procedures on complaints were clearly written and accessible to the service users and their relatives and friends. No complaints had been made to the home since the last inspection. A Hounslow manual on the protection of vulnerable adults was in place and it was confirmed on records seen that training in adult abuse had been delivered to the care staff. The Registered Manager confirmed that service users legal rights were protected and that if required, advice regarding legal matters would be made accessible. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25 and 26. The home is well maintained and the environment is safe, comfortable and pleasant. EVIDENCE: The home was found to be clean, attractively decorated and well maintained throughout. The communal areas were spacious, comfortably furnished and suitable for shared or individual activity. The large surrounding gardens and patio areas were tidily kept and easily accessible to wheelchair users. A number of service users’ bedrooms were viewed during the inspection. All were tidy, suitably fitted, reflected personal choices and contained en-suite facilities. The additional toilet and bathroom facilities were hygienically clean and appropriate for meeting the personal needs of the service users. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 16 There were a variety of specialist equipment at the home including hoists, grab rails, assisted baths, walking aids and nurse call systems. There were also two passenger lifts. The overall environment at the home was safe, homely and peaceful. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. The home’s recruitment policy was satisfactory and care staff received appropriate training in meeting the needs of the service users. EVIDENCE: The Registered Manager reported that the home did not use Agency staff. It was reported that forty-one permanent care staff members, three cooks and three domestics were employed at the home. Six members of the care staff covered the day shifts and three waking care staff members were on duty during the night. A number of personnel files were viewed at random. All contained the required documents and it was indicated on training certificates that training had been delivered in Moving and Handling, Fire Safety, Health and Safety, Dementia, Challenging Behaviour and the Protection of Vulnerable Adults. The Registered Manager confirmed the 50 of the care staff had obtained levels 2 or 3 NVQ qualification. Members of the care staff who spoke to the Inspector expressed satisfaction with the working conditions and the support they received within the home. The level of staff present at the time of the inspection was appropriate for meeting the needs of the service users. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) ,32,33,35,36,37 and 38. The home is satisfactorily managed and the safety and welfare of the service users and staff are essentially protected. However, records in relation to staff supervision and some health and safety checks were not available at the time of the inspection. EVIDENCE: The Registered Manager and Deputy Manager are experienced and appropriately qualified. The home is organised, well run and focused on meeting the needs of the service users. Members of the care staff were observed to respond sensitively and competently to the needs of the service users. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 19 Although the Inspector was informed that care staff received regular supervision, no records of recently held supervision sessions were available. Health and safety checks in relation to the lifts, water temperature, fire safety, portable electrical appliances and testing for legionella were up to date. However, documents relating to recent gas and electrical maintenance checks were not accessible. It was noticed also, that the cupboard containing COSHH products was unlocked. The Deputy Manager explained that these products were in use during the inspection. Risk assessments on health and safety awareness within the home had been appropriately undertaken and these were regularly reviewed. Responsibility for the financial affairs of many of the service users is held by the home. The financial records of five service users were examined and all were found to be satisfactory. It was evidenced that the overall safety and welfare of service users and staff were being secured at the home. Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 2 3 2 Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 36 Regulation 18(2) Requirement The Registered Person shall ensure that persons working at the care home are appropriately supervised. The Registered Person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Timescale for action 31/10/05 2. 38 13(4)(c 30/9/05 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 Good Practice Recommendations Maryville Care Home G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ground Floor 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 G61-G10 s22899 Maryville Care Home v214276 240805 Stage 4.doc Version 1.40 Page 23 - 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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