Inspection on 05/01/06 for Masson House

This inspection was carried out on 5th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Masson House 11/03/09

Masson House 24/07/06

Masson House 02/03/05

Masson House 02/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Masson House 86 Derby Rd Matlock Bath Matlock Derbyshire DE4 3PY Lead Inspector Angela Kennedy Unannounced Inspection 5th 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 Masson House DS0000020052.V270497.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. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Masson House Address 86 Derby Rd Matlock Bath Matlock Derbyshire DE4 3PY (01629) 55740 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) Mr Brian Richard Boam Mrs Hazel Teresa Boam Mrs Hazel Teresa Boam Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: Masson House is a listed building and is approximately 250 years old. The care home is situated opposite Masson Mill on the outskirts of Matlock Bath. Set within woodlands grounds, only the frontage of the building is accessed by residents and visitors. The care home provides residential care for up to 17 older people with a wide range of personal care needs. Accommodation is provided on three floors, with access to all floors by shaft lift or staircase. Three of the bedrooms are suitable for shared occupancy and three of the bedrooms are equipped with en-suite facilities. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 2 hours. A tour of the building took place. Discussions were held with six of the residents. There were no relatives present to speak with during the inspection. A number of records were examined during the inspection and an assessment was also made of the progress by the registered persons to address requirements made at the previous inspection of the home. What the service does well: What has improved since the last inspection? Detailed documentary evidence of risk assessments for resident’s wishing to self medicate are now in place, this demonstrates that all reasonable efforts have been made to maintain residents safety. Window restrictors are now in place in line with Health and Safety Executive guidance. This demonstrates that every effort has been made to limit the risk of injury to residents. Radiator covers are now in place within most areas of the home, this is an ongoing maintenance and health and safety initiative, risk assessments are in Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 6 place for radiators that at present do not have covers. This demonstrates that every effort is being made to minimise the risk of injury to residents. 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. Masson House DS0000020052.V270497.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 Masson House DS0000020052.V270497.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): EVIDENCE: Standards 1 – 5 were not inspected at this visit. Standard 6 is not applicable to this care home. Masson House DS0000020052.V270497.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 Care plan documents, including risk assessments are satisfactory. The documentation for self – medication arrangements are in place. This demonstrates that staff have the appropriate information when caring for residents. EVIDENCE: Of the care plan files examined, risk assessment were in place to determine the specific risk of residents falling. This was a recommendation following the last inspection, which has now been met and demonstrates that a proactive approach to resident’s safety is in place. A thorough risk assessment is now in place for residents who wish to self medicate, this was a requirement following the last inspection at the home. This provides greater levels of safety for residents and clearer directions to staff. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 10 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): 12,13,15 Social and leisure activities are arranged by the home, these are mainly based within the home. Residents maintain contact with family and friends. The catering is reported by residents to be of a good standard. EVIDENCE: Residents spoken with talked about the activities that were available at the home, this included a pantomime that was to be held at the home on the following weekend, which many of the residents appeared to be looking forward to. One resident in particular talked about their interest in the performing arts and appeared very enthusiastic regarding the forthcoming pantomime. Other activities at the home included pottery, reminiscence groups an activity linked with the work of one of the local schools, musical entertainment and non-denominational religious services or activities. One resident at the home had been awarded a senior learner of the year certificate. The manager of the home stated that activities outside of the home were organised when possible but staffing levels often challenged these activities – as the home is not large and has limited staff numbers to call upon. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 11 Of the residents spoken with, all were happy with the homes visiting arrangements, which had an open visiting policy, many of the residents spoken with talked about their families and friends who were able to visit them when they so wished. The residents spoken with appeared happy with the meals provided at the home, one resident spoken with stated that the standard of cooking and portion size of meals was more than satisfactory. The manager stated that at present a cook was employed at the home working one regular day each week and alternative Saturdays, meals were prepared and cooked by the manager the remainder of the week. However, a new cook was due to commence employment the following week to cover these shifts. Masson House DS0000020052.V270497.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): 16,18 There is a complaints system in place, which demonstrates that the manager follows up any concerns. The systems in place promote the protection of the residents from abuse and neglect. EVIDENCE: There is a complaints procedure in place within the home, a copy of this is displayed on the notice board and states the timescale for response to complaints i.e. maximum of 28 days. However this timescale also needs to be included in the written information about the home that is available to residents, prospective residents and other interested parties. The residents spoken with said that the manager acts on any issues or concerns that are raised by them. The homes has a policy on adult protection and has purchased an educational pack that is robust in detail and will assist the staff team in promoting the protection of their residents from abuse and neglect, however this needs to link with local authority guidelines, to ensure clear guidance is available to staff. Masson House DS0000020052.V270497.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): 19,20,24,25,26 There is a warm, homely feel to the building. Despite the challenges that are presented due to the age and listed status of the home, residents have access to safe and comfortable communal and private facilities. EVIDENCE: The home and grounds are approximately 250 years old and have a listed status. This ultimately presents some challenges in the maintenance of the home. However the sash windows fitted have recently undergone maintenance and the previous requirement to provide a maximum of 100mm opening has now been met through the use of window restrictors. The majority of radiators within the home now have covers to protect residents from heat injury. Assessments are in place for radiators that do not have covers. Residents spoken to considered the environment to be homely and the staff team on the day of inspection created a warm and friendly environment. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 14 Apart from the staircase there is access to all floors via a shaft lift, this enables residents to access their private facilities and the communal areas of the home safely. Many of the residents had personalised their private accommodation with their own possessions thus making their own private rooms homely. The home appeared clean on the day of inspection and no unpleasant odours were detected. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 15 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): 28,29,30 Residents are supported and protected by the homes recruitment practices and felt that the staff team looked after them well. Staff at the home have undergone the appropriate training to meet the residents needs. EVIDENCE: The residents spoken with were very complimentary about the care they received from the staff team, and stated that the staff were kind and friendly towards them. Staff were observed to be both friendly and respectful towards the residents. A sample of the recruitment documentation was examined; this confirmed that the appropriate employment checks were in place. The manager stated that there was an intention for volunteer staff to work at the home once all the required information and documentation checks had been received. The presence of the regulatory checks further assures the safety of residents. The home has attained the 2005 targets for the ratio of staff within care settings to achieve National Vocational Training Qualifications. Of the 11 staff employed at the home, 1 has achieved an NVQ (National Vocational Qualification) level 3 in care and 5 staff have achieved NVQ level 2 in care. A sample of the staff training and development programme was examined and found to be satisfactory, this further demonstrates that staff are trained and competent to meet the needs of the residents. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 16 The manager stated that the majority of the training undertaken was done inhouse due to the staffing levels of the home. Staff at the home met the requirement of a minimum of three paid training days a year. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 17 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): 31,33,35,38 The manager of the home has many years of experience but has not yet undertaken the qualifications identified within the standards. To permit interested parties to form a judgement of the service and to evidence that residents influence the service, the results of the residents survey need to be published. The health, safety, welfare and financial interests of the residents are protected. EVIDENCE: The manager (also one of the registered providers) of the home has many years experience within the role as manager. However she has not yet undertaken the qualifications identified within the National Minimum Standards (care and management qualifications). This is a previous requirement that has been made for the manager to register to undertake this qualification. The Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 18 manager on discussion stated her intention to commence this training hopefully in Spring 2006. The result of the survey of resident’s views demonstrates that feedback from the residents is sought to ensure the service is run in their best interest. However, this information needs to be published, discussions took place with the manager as to how this could be achieved. Once a system has been established to publish the results of such surveys it will demonstrate how residents at the home are able to affect the way the service is delivered and it will provide information to residents, prospective residents and other interested parties. Residents monies are not kept by the home, although residents are able to keep their own money, the majority do not. Any purchases required by residents are bought by the home and then reimbursed by the resident’s relatives/representatives as required. Receipts are kept of any purchases made. Records and receipts are kept of any resident’s possessions that are handed over for safekeeping. A`sample of the Register of Valuables Held was seen, this included; valuables received by the home, valuables returned and valuables checked. Staff at the home have received safe working practices training in; moving and handling, first aid and food hygiene, the presence of these training practices demonstrates that efforts are being made to promote the health, safety and welfare of the residents. Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 19 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 2 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 20 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 16 Regulation 22(4) Timescale for action The complaints procedure (within 28/02/06 service user guide /statement of purpose) must include the timescale for response to complaints Radiator covers in respect of 31/03/06 uncovered radiators must be fitted to reduce identified risks. The manager must register for 30/04/06 the relevant management and care qualifications (as per current CSCI guidance) The results of the service user 31/03/06 survey must be published and made available to current and prospective service users, their representatives and other interested parties including CSCI. Requirement 2 3 25 31 13 (4) 9 4 33 24 (1,2) Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 21 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 18 Good Practice Recommendations The homes adult protection procedures should include details of how this links to local guidance (Derbyshire Adult Protection). Masson House DS0000020052.V270497.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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