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Inspection on 30/08/05 for Mauricare Residential Home

Also see our care home review for Mauricare Residential Home for more information

This inspection was carried out on 30th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents` families continue to be involved in the daily lives of their relatives in the home, visiting is welcomed on an open basis and families feel welcomed in the home. Care plans are individually detailed, and a number have information from health professionals and specialist staff. Service users who have a planned admission have their needs are assessed prior to moving into the home. The premises are adequate for their purpose. All areas inspected were clean and tidy, with residents able to have their own possessions in their bedrooms. A range of social activities are offered in the home. Residents can choose how what they do on a daily basis; subject to risk assessments and particular care needs. Meals provided are nutritious and residents are given choice. Health care needs are mainly well met, and residents have access to treatment when they need it. Medication is securely stored and stock levels at an acceptable level.

What has improved since the last inspection?

Residents were seen to be assisted in an appropriate manor, staff were communicating with residents in a relaxed and supportive way.

What the care home could do better:

The recording of medication is an area that could be improved, as there a need for staff to clearly record the medication dispensed. The policies and procedures of the home require reviewing, and personalising to the management style now being adopted. The homes statement of purpose and Service User guide also require to be updated with the recent changes. Resident assessments and care plans require be regularly reviewed and updated, the information in some of these is quite dated and requires some effort to make it accurate. The recruitment procedures for new staff requires to be tightened, and all new staff be thoroughly vetted prior to commencing employment in the home. Staff training, supervision and appraisals for all staff should be planned and recorded appropriately. Meetings for residents and staff should be planned in advance; and in conjunction with a quality assurance framework questionnaires, be circulated to associated individuals, and findings be fed back into the Statement of Purpose. Staff could record more fully in daily records activities that residents have been involved in, to better show that they are meeting the full range of social and recreational needs.

CARE HOMES FOR OLDER PEOPLE Arundel 22-24 Fosse Road Central Leicester Leicestershire LE3 5PR Lead Inspector Keith Williamson Unannounced 30 August 2005 at 9.00am 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. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Arundel Address 22-24 Fosse Road Central Leicester Leicestershire LE3 5PR 0116 2513785 0116 2513785 None Mauricare Limited 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) Vacant Care Home 17 Category(ies) of OP Older Persons - 17 registration, with number MD(E) Mental Disorder over 65 - 17 of places MD(E) Dementia over 65 - 17 A Alcohol depend past/present - 4 DE Dementia - 1 SI Sensory Impairment - 3 Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No one falling within the category SI may be admitted into the home where there are 3 persons of the category already accomodated in the home. No one falling within category A may be admitted into the home where there are 4 persons of category A already accommodated within the home. Date of last inspection 11-4-05 Brief Description of the Service: Arundel Residential Home is situated on Fosse Road Central in the City of Leicester. This moderately sized home has space for 17 Older Service Users. The home specialises in providing care for Service Users with Dementia and Mental Health. The home is a converted property, and accommodation is on 3 floors, and these are accessed via a passenger lift. The bedroom accommodation is spread throughout the three floors of the building; there is a mixture of double and single accommodation, some with en-suite facilities. The home is well situated for travel into town by bus, and is reasonably placed for the local amenities, which offers a mix of shops, restaurants and cafes. There are also parks and open space nearby. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one weekday, commencing at 9.30am took 5 hours to complete, and was assisted by the deputy manager. An opportunity was taken to look around the home, view records, policies and care plans and to talk to staff and residents and their relatives. Six of the residents were seen during the inspection however few were able to give the inspector their impressions of the home, one relative was also seen during the inspection and passed comment on the home. This is the first inspection of this service with the new owner who took over a brief time ago, no manager is yet in place, and though the inspection findings indicate some work to be undertaken, it is envisaged the employment of a manager will clarify the overall direction of the home and raise the quality of care for residents. What the service does well: What has improved since the last inspection? Residents were seen to be assisted in an appropriate manor, staff were communicating with residents in a relaxed and supportive way. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 6 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. Arundel C51 C01 S6357 Arundel V246127 300805 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 Arundel C51 C01 S6357 Arundel V246127 300805 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) 3. The admission process is followed consistently for all planned admissions. EVIDENCE: Pre - admission assessments were seen on residents files viewed in the home, and are used consistently in the admission process, however some of these are now out of date and require to be updated with each residents’ current abilities. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 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 standard(s) 7 & 9. Residents are looked after well in respect of their health and personal care needs. EVIDENCE: Care plans are in place, are detailed on a personal basis and are reviewed periodically. Residents and their relatives are included in the care planning process, though some have elected not to participate. Staff were viewed giving out medication, an issue arose of how a prescribed medication is being recorded; as it is a varying dose on alternating days. Clarity must be given to this process and all staff instructed on how to record this appropriately. Staff spoken with had a limited understanding of the medication process. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 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 standard(s) None All standards in this section were visited on the first inspection of this service earlier in 2005/06. EVIDENCE: Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 11 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) 18. Staff lack specific knowledge on Adult Protection to protect residents from abuse. EVIDENCE: The adult protection policy and procedure are in place, it was not ascertained if the registered person has received the revised version of the multi-agency procedures; it is expected by the inspector these shall be shared with staff in the near future. Through speaking with staff it was apparent that they have limited knowledge of adult abuse and the whistle blowing procedures. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 12 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 & 26. The home is generally safe, and partially meets the needs of residents in the home. EVIDENCE: A number of outstanding requirements remain from the last inspection; work is required to ensure these are put in place promptly. The Fire Risk Assessment, plan of routine maintenance and reports from the Environmental Health Officer and Fire Officer were not available for view on this occasion. The general décor in the home is “tired” and the plan of routine maintenance suggested at the last inspection, that all the public areas within the home were to be redecorated before September 2005; this timescale has been extended since the new owner has taken over, and plans are in place for general upgrading of several areas but no completion date has yet been offered. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 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 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) 29 & 30. Residents are not supported by a well-trained staff group. EVIDENCE: There have been a number of staff changes resulting in the recently appointed staff not having the appropriate pre-employment checks in place prior to commencing in the home. Staff training is in place, though again with a number of new staff having commenced, an overall training programme is necessary for the resident group to fully benefit from the planned staff training. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 14 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) 33 & 38. The management approach does not promote effective care practice in the home to ensure residents’ care and protection. EVIDENCE: No evidence of recent residents meetings or quality assurance questionnaires was offered at the inspection. A number of tests and checks on the fire alarm system have not been completed recently. It is imperative these are re-commenced to ensure resident safety. Evidence of other safety tests could not be found, it is envisaged that the registered person ensures these are undertaken periodically. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 15 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 3 x x x x 2 Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 16 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 9 Regulation 13 (2) Requirement The Responsible Individual must ensure that staff administering medication in the home, do so in a safe and accurate manor, and the process followed is in line with the current homes policy and procedure on medication administration. The Responsible Individual must ensure that the Fire Risk Assessment is updated and made available at future inspections. The original timescale of the 15th May was not met. The Responsible Individual must ensure that the plan of routine maintainance covers all areas of the home, and include the routine cleaning and disinfecting of areas. The original timescale of the 15th May was not met. The Responsible Individual must ensure that any outstanding work from the Environmental Health Officer and Fire Officer reports must be actioned, and these reports be made available at future inspections. The Responsible Individual must ensure that all staff employed in Timescale for action by the 30th August 2005. 2. 19 17 (2) (3) by the 13th September 2005. 3. 19 12 (1) a by the 13th September 2005. 4. 19 12 (1) a within the timescale set in the report. 5. Arundel 29 19 (1) by the 13th September Page 17 C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 6. 38 12 (1) a 7. 38 12 (1) a the home have the appropriate pre-employment checks in place. The Responsible Person must ensure that the tests performed periodically to ensure resident safety in the home are put in place and the appropraite staff or external body action those within the required timescale. The responsible person must ensure that all Risk Assessments are put in place, for individuals and the premises. 2005. by the 13th September 2005. by the 13th September 2005. 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. 3. 4. 5. 6. 7. Refer to Standard 3 7 9 18 30 33 33 Good Practice Recommendations It is recommended that all residents are re-assesed periodically. It is recommended that all care plans are reviewed periodically and re-written on a re-assesed. It is recommended that all care staff have planned and accredited medication training. It is recommended that all staff be instructed in the adult absue and whistle blowing policy and procedures. It is recommended that a thorough staff training programme be put in place. It is recommended that residents have periodic meetings to discuss the development of the home. It is recommended that Quality Assurance questionaires be circulated to residents, their relatives and other individuals, proffessionals and stakeholders, and the findings of those be entered in the Statement of Purpose or Service User Guide. Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Arundel C51 C01 S6357 Arundel V246127 300805 Stage 4.doc Version 1.40 Page 19 - 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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