Inspection on 08/01/06 for Matthias House

This inspection was carried out on 8th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Matthias House 23/05/07

Matthias House 22/09/05

Matthias House 24/11/04

Matthias House 24/06/04

Matthias House 24/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Matthias House 107 Dudley Road Tipton West Midlands DY4 8DJ Lead Inspector Mike Kirton Unannounced Inspection 8th February 2006 09:00 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 Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Matthias House Address 107 Dudley Road Tipton West Midlands DY4 8DJ 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) 0121 522 2049 0121 557 0528 Dr George Osho-Williams Mr Julian Timmins Beverley Louise Elwell Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd September 2005 Brief Description of the Service: Matthias House is a private residential home registered to provide 24-hour care for 33 people over the age of 65. The home is situated on the Dudley Road in Tipton, next to the church and was originally a vicarage, which has now been extended. The home is easily accessible by public transport and there are a number of local shops and other amenities within walking distance. Accommodation is provided over 2 floors, accessible via the main staircase or passenger lift with the 3rd floor used as offices and staff room. There are 4 double bedrooms (2 with en-suit toilets) and 25 single bedrooms (17 with ensuit toilets). There are a 4 lounge areas, 1 of which adjoins the dining room; this can be partitioned off. Car-parking facilities are provided at the front of the building and there is a separate car park approximately 100 yards to the side of the property (right side facing the home). The entrance to the property is ramped to enable wheelchair users to easily access the home. To the rear of the property there is a well-maintained garden with seating areas, trees, shrubs and flower borders. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and included a tour of the buildings, interviews with the deputy manager and informal discussions with residents and staff on duty. Health and safety records, 3 individual care plans, and 3 staff files were also examined. What the service does well: 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. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 6 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 Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 7 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: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 22nd September 2005. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 8 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 22nd September 2005. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 9 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 22nd September 2005. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 10 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 The manager has taken more than sufficient measures to ensure that everyone is aware of how to make a comment or complaint about the service they receive. The necessary procedures have been implemented to reduce the risk of residents experiencing any abuse. EVIDENCE: The homes complaints procedure meets all the required standards and includes contact details for the Commission should anyone wish to raise concerns directly. Copies are clearly displayed and included in the homes statement of purpose. They are also given to each resident and/or their representative who signs to confirms that they are aware of their rights. A copy of the local authorities social services adult protection procedures was available. The home also has their own procedures including whistle blowing, which have been signed for by staff to evidence that they have been read and understood. Contact phone numbers were also displayed in the office to ensure all relevant service are informed should any allegation be made. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 11 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, 26 The home has a comfortable, relaxed, and homely atmosphere and provides a generally safe environment for residents to live. Standards of repair furnishings and decoration were not as good as on previous inspections and care should now be taken to ensure standards do not fall. EVIDENCE: A tour of the buildings took place including lounge, dining, kitchen, and laundry facilities. The home has 2 distinctive styles with the older original building contrasting with the modern extension. All areas were generally well decorated, clean and tidy however a few repairs were noticed (recorded under standard 38 of this report) and carpets, woodwork, decoration, and some furniture needed repair or replacement. The owners must also take into consideration the needs of resident when choosing floor coverings for example sight difficulties and/or memory loss. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 12 The exterior of the building and surrounding groups were well maintained. Gardens were landscaped and allowed access for people with disabilities. Health and safety procedures displayed in the laundry were being followed. Discussions took place with the staff responsible who explained the steps taken to ensure the risks of cross contamination were kept to a minimum. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 13 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, 30 All staff met on the day of the inspection were friendly, approachable, and interacted well with the residents. Whilst there are some good recruitment, training, and supervision procedures in place these require further improvements particularly. EVIDENCE: The staff rosters that are were displayed on the wall outside the main office along with individual photos, and 3 personal files were examined. Normally the home provides 5 care workers on duty during the day in addition to the manager and domestic staff and 2 at night. Currently this was not being maintained every day due to sickness and vacancies. The home however was not full and only 29 residents were present. It is the homes policy to implement a 6-week induction followed by foundation training or NVQ 2 in care as a minimum. All new staff sign to confirm that they have read and understood the homes policies and an individual training plan is implemented. Supervision is also provided on a regular basis and planned in advance with records kept. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 14 Staff files contained a copy of their application form, interview notes, criminal record check, 2 references, proof of identification and medical check. There was no evidence however that the manager received confirmation that they were not on the list of people who might harm vulnerable adults (POVA). A record must also be kept of previous employment histories including reasons for leaving. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 15 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 Although the manager was not present during the inspection all the necessary information was available, easy to find, and well structured. Steps should be taken now to ensure that the home continues to be maintained to a high standard and repairs are identified and corrected quickly. EVIDENCE: Bev Elwell is registered with the Commission, has many years experience and the necessary knowledge and training to manage the home to a very high standard. The home has a quality assurance system in place and have obtained the views of some residents and visitors to the home. This requires developing further in line with standard 33 with results published on an annual basis and action plan implemented for further improvements. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 16 Resident’s money is handled by themselves, their relatives, or through an appointee. Small amounts can be held by the home. This is kept in individual wallets, signed by staff following any transaction and is regularly audited to ensure accuracy. The homes policy states that staff must not offer any financial advice. Records required ensuring the health and safety of staff and service users were inspected. Fridge, freezer, water, and cooked meat temperatures were recorded. The homes gas landlords certificate, 5-year electrical wiring test was in date and portable electrical equipment was tested. Risk assessments on the building and staff/service users activities is completed and reviewed every 12 months and public liability insurance was in place. A fire risk assessment and evacuation plan is in place, and all equipment is regularly serviced and tested as required. A fire lecture has been planned for 09/02/06 to which all staff are invited to attend. This includes updates and role-playing different fire scenarios. A few repairs were identified during the inspection of the building, which had not already been noted by staff. This included a loose radiator cover, broken lock on a shower room door (although this was being used as storage) missing fire extinguisher sign, and the laundry fire door did not close into the frame. It was also identified that regulation 37 reports were not being sent to the Commission as required for notifiable incidents. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 2 Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 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 OP29 Regulation 18, 19 Requirement Confirmation must be received that new staff are not on the POVA list before they begin work. Timescale for action 08/02/06 2. 3. OP33 OP38 A record must be made of an individual’s employment history including reasons for leaving. 24 The homes quality assurance system must be developed further in line with this standard. 12, 23, 37 Regulation 37 reports must be sent to the Commission as required for notifiable incidents. All repairs identified during the inspection and recorded in the report must be carried out. 01/04/06 15/02/06 Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 19 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. 2. Refer to Standard OP19 OP38 Good Practice Recommendations Patterns on floor coverings should be avoided. Installation of a door alarm to notify staff in case the upstairs fire exit door is opened. Matthias House DS0000004778.V282125.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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