Inspection on 01/08/07 for Mavesyn Ridware House

This inspection was carried out on 1st August 2007.

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

Mavesyn Ridware House 30/03/10

Mavesyn Ridware House 18/01/10

Mavesyn Ridware House 13/02/09

Mavesyn Ridware House 08/07/08

Mavesyn Ridware House 12/12/06

Mavesyn Ridware House 19/04/06

Mavesyn Ridware House 23/01/06

Mavesyn Ridware House 08/09/05

Mavesyn Ridware House 17/01/05

Mavesyn Ridware House 19/07/04

Mavesyn Ridware House 12/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Mavesyn Ridware House Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB Lead Inspector Rachel Davis Unannounced Inspection 09:45 1 August 2007 st 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 Mavesyn Ridware House DS0000004978.V339750.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. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mavesyn Ridware House Address Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB 01543 490585 F/P 1543 490585 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 Malcolm William Hurst Mr Frederick Hooson Mrs Sandra Margaret Black Care Home 21 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (8) Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 Brief Description of the Service: Mavesyn Ridware is located off a public transport route near to Armitage and Handsacre. It provides care and accommodation to 21 older people. The home is registered to accommodate six people who have dementia care needs, and eight may have a physical disability. The fee level for the home is £389 to £425 per week, this does not include extra services such as hairdressing, chiropody, toiletries or newspapers. The home stands in its own grounds with stunning views, the gardens are well maintained and offer appropriate seating areas for the people who use the service. Mavesyn Ridware has a large lounge, conservatory and separate dining room. Bedrooms are single occupancy and some have an en-suite facility. The registered manager for this service is Sandra Black. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over eight hours, this was a ‘key inspection’ and therefore all the core standards were assessed. The methodologies used were: A day of preparation before the inspection, including scrutiny of the Annual Quality Assurance Assessment completed by the owner, questionnaires returned by the people who use the service and their relatives. The health care professionals questionnaires sent by the Commission for Social Care Inspection and Mavesyn Ridware were not returned. The Commission for Social Care Inspection met and spoke to the people living in the home and the majority of staff on duty. There were no visitors seen by the Commission for Social Care Inspection on this occasion. Observations were made of staff and resident interaction around non-personal care tasks, the medication administration was also seen. A tour of the home was taken and some of the people living in the home showed the Commission for Social Care Inspection their bedrooms. Care plans were checked and the records of three staff including recruitment and training documents were seen. There have been no complaints made to the Commission for Social Care Inspection about the service delivered at Mavesyn Ridware since the last inspection. What the service does well: Mavesyn Ridware has a stable staff group therefore offering the people who use the service continuity of care. The manager does not admit anyone into the home unless their needs have been assessed. A plan of care is developed for all of the people using the service, which covers all areas of need, physical, emotional and spiritual. They are regularly reviewed and amended as changes occur. The people using the service and/or their families can be involved in this process, although some did not know this. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 6 Comments from the relatives were generally positive regarding the quality of care provided in the home. Some of these are included in the main body of the report. The people who use the service have access to a range of medical professionals to maintain their health and wellbeing. Families and visitors are made welcome. The food is home-cooked and there is a plentiful supply of fresh fruit, vegetables and milk. Choices are available, which are taken advantage of by some of the people using the service. The Commission for Social Care Inspection has not received any complaints about the service since the last inspection. All of the people involved in this inspection were positive about the staff and their caring attitudes to the people using the service. What has improved since the last inspection? What they could do better: More work is required to ensure that the home is able to meet the needs of people with dementia or communication difficulties. This includes more stimulation and activities and evidence that they, wherever possible are enabled to make choices. The Statement of Purpose and Service User Guide need to be reviewed and offered to all people who use the service. There needs to be better evidence to confirm the home is able to meet the diverse needs of the people who use or may use the service. Although care plans and risk assessments are developed for the people who use the service there is room for improvement. Plans of care should be person centred and give a picture of the individual, it is important to sign and date all paperwork. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 7 Mavesyn Ridware is clean and tidy but some redecoration and refurbishment is needed to ensure that the people using the service live in safe environment. The home does not have robust individual fire risk assessments for the people who use the service. Controlled Drugs are not presently being satisfactorily recorded. The registered manager works full time and on most occasions has to work on shift, the manager must be offered the time, support and supervision required to fulfil her role and complete the tasks expected of her. 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. The summary of this inspection report can be made available in other formats on request. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 8 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 Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4. Standard 6 is not applicable. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are not admitted into Mavesyn Ridware without prior assessment; this ensures the home is confident that individuals needs will be met. EVIDENCE: The homes’ Statement of Purpose and Service User Guide were not inspected but were seen on this occasion, it was evident they had not been reviewed. Through discussion with staff it was clear that the people who use the service do not receive a copy, therefore current and prospective residents and significant others are not offered the opportunity to make an informed choice about the services provided and whether the home can meet their needs. The home should consider how people who use the service with specialist needs can receive the necessary information, as the present Statement of Purpose and Service User Guide are not particularly “user friendly.” Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 10 The previous inspection report was available to read at the home as required. People admitted into the home have an appropriate assessment, the home should consider ways in evidencing equality and diversity within their service and how they support people with more complex needs. The manager has completed the paperwork on admission to a satisfactory standard. Two out of eight questionnaires sent by the Commission for Social Care Inspection to relatives were returned, it asksQ1. Do you get enough info about the home? Both replied usually– one said, “When you ask the staff they are very helpful” Mavesyn Ridware does not provide intermediate care. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Overall the health and personal care needs that people who use the service receive are suitable but they could be improved upon. The principles of respect, dignity and privacy are practiced. EVIDENCE: The care records of four people who use the service were checked during this inspection. In all cases, a plan of care has been developed and reviewed. The manager is starting to consider and devise a person centred care plan these should include information around areas of need such as personal care, recreation, nutrition, spiritual needs, hobbies, sexuality etc. Satisfactory information was found in the one care plan where this has occurred but it could delve deeper to get a real person centred view. Daily records were well recorded and contained meaningful information. Risk assessments are satisfactory. The majority of those spoken to confirmed they were happy and commented: Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 12 “The staff are kind to me.” “They are helpful.” “My relative receives excellent care.” One returned questionnaire stated: “The physical care and support of my relative is very good. The staff are very sensitive in the manner the both handle my relative and other people who use the service. I have seen this when I visit.” The staff and records can evidence that the residents’ health is monitored and the appropriate professionals contacted on their behalf. Staff were observed in their approach to residents during the visit. They were seen to afford dignity and respect. It was evident during the inspection process that some areas of need for specific individuals were not in place, these were discussed and addressed with the people who use the service and the manager during the inspection. The Commission for Social Care Inspection will follow up these issues to ensure that suitable systems and choices have been provided. It was noted in one instance that bed guards were not being used appropriately, it was also ascertained that the bed guards being used had not been assessed for the individual, and this must be addressed without delay. Medication was checked on this inspection and observed, it was administered appropriately. The controlled drugs were not being suitably recorded and one resident requires an assessment around self-medication. The home must develop a programme to assess and monitor the staffs’ competency in administering medication to the people who use the service. Medication Administration Sheets had been completed, a signature sheet was in place and the drugs trolley was clean and tidy. The home has not returned any medication since 26/05/07, excess stock was seen and should be returned as soon as possible. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. For some people who use the service the variation, activities and interests at Mavesyn Ridware appear limited. The home encourages and welcomes visitors. EVIDENCE: The home operates a key worker system, which enables closer resident staff relationships where likes, dislikes and needs are shared and should also be recorded. People who use the service were asked: Are there activities arranged that you can take part in? 1 said always 4 said usually – “music and movement, sometimes a sing along, parties for birthdays.” 2 said sometimes Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 14 During the inspection one person who uses the service stated they were “bored” another said, “It can be very dull.” The questionnaires sent to the people who use the service and their relatives ask: How do you think the care home can improve? The answers were: “There appear to be limitations on activities.” “The television is the main source of entertainment” A requirement around stimulation and activities has been made. From the records available it was clear there were regular visitors to the home. Questionnaires confirmed they were made welcome at any time. A number of people who use the service said that they went out of the home with relatives and friends. People who use the service were able to receive visitors whenever they chose, as the home has an open visiting policy. People who use the service confirmed they could choose to see their visitors within their own private accommodation if they preferred to do so. The home has one dining area, which was pleasant, clean, and the tables were nicely laid. Four people who use the service said they usually liked the meals, 3 said always. The Commission for Social Care Inspection asked 7 people who use the service what was for dinner, no-one knew. It was ascertained that residents used to be asked but this now rarely happens, an alternative meal is always available. The cook has a 4-week menu, 3 people who use the service said it was “repetitive.” All of the meals are ‘home-cooked’ and home-baked cakes and puddings are available. The kitchen is well maintained, it was inspected and found to be clean and tidy. It was particularly hot (although not a particularly hot day), the home may wish to look at further ventilation to assist the cook. All the required records were in place although not all daily cleaning tasks were being recorded as undertaken. Food supplies were plentiful and fresh fruit and vegetables were available. Records of fridge and freezer temperatures were kept. The home must ensure all opened jars that have a recorded expiry date are labelled, with an opened and use by date. A discussion was held at this inspection as to whether choices could be expanded. It is particularly difficult to offer choices to people with dementia, who either forget what they asked for or in many cases cannot communicate Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 15 their wishes. The cook could look at offering more visual choices such as developing menus in photo format. The residents may like to choose their own vegetables from a separate dish or decide whether they fancy gravy or a sauce that day by having them in sauceboats or jugs. Two liquidized meals were evident, these were poorly presented in a bowl with all parts of the meal blended together, this does not offer people any variety of taste, texture, colour or visual stimulation. The kitchen was inspected on this visit, fresh meat, fruits and vegetables were delivered and the dry stores were well stocked. All areas of the kitchen were clean and well presented; crockery and cutlery were of a good standard. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure but there needs to be evidence to confirm that people who use the service are encouraged to express their concerns. Training in the protection of vulnerable adults has been provided to all staff. EVIDENCE: The service has a complaints procedure that is available but people who use the service would have to ask for a copy because they do not receive a Service User Guide. No evidence was seen to verify if it is made available in a wide variety of formats (including variety of languages, tape, Braille, symbol, large print) to enable everyone associated with the service to complain or make suggestions for improvement. Questionnaires sent by the Commission for Social Care Inspection asked: Do you know who to speak to if you are unhappy? Everyone replied always – and one person recorded “I am able to make my concerns known if I have complained.” When asked - Do you know how to complain? Six said yes and only 1 said no. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 17 The home has not received any formal complaints since the last inspection, minor comments, complaints or grumbles have not been recorded as necessary. This was discussed with the manager during the inspection. Recording all matters will enable the home to see if there are any patterns and trends and also evidences that the manager is open and transparent and happy to record issues and outcomes. Not recording concerns etc does not allow the home to evidence that it has learnt from the process, and the same issues do not reoccur. It was recommended that all areas of concern expressed by the people who use the service, their families or other stakeholders and professionals are recorded as evidence that the management are transparent and take people’s concerns seriously. The financial systems were checked. Monies held by the home are done so safely and records kept. Signatures and receipts are obtained for all transactions. The policies and procedures regarding protection of people who use the service are in place, no vulnerable adult referrals have been made. A training matrix confirmed staff have received training in the Protection of Vulnerable Adults. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is clean and hygienic but requires some redecoration and refurbishment to make it safe for the people using the service. EVIDENCE: Mavesyn Ridware is a clean and comfortable and has a homely feel. All questionnaires returned confirmed that this is so. When asked: Is the home fresh and clean? All 7 people who use the service responded always, one person who uses the service wrote: “ The home is clean and tidy and always welcoming.” Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 19 Infection control measures are in place, examples of this include: paper towels, liquid soap, laundry management and personal protective clothing. The home is sluicing underwear in buckets, this practice is outdated and does not comply with infection control standards and must cease. The home should consider purchasing alginate bags to assist with soiled laundry. The bathroom downstairs is in need of refurbishment, apparently this is within the business plan and will be addressed this year. It is not clear if there is a risk assessment for the slope leading to this area, if not then this must be completed, also one other slope on the downstairs corridor does not have a grab rail, this again should be assessed. There is a large garden to the property, which is well maintained, the people who use the service stated they enjoyed sitting outside, a gazebo and seating were available. It was noted that a number of windowsills were rotten/ rotting, a recommendation to check their safety and suitability was made. The home employs a maintenance person who carries out any required maintenance on an ongoing basis, only the fire testing and emergency lighting were checked on this occasion. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager ensures that the home is staffed at all times by a sufficient number of trained personnel. EVIDENCE: The number of staff on duty during the inspection was suitable to meet the needs of the people who use the service. Three staff files were examined and they demonstrated that a suitable recruitment practice is now in place, this included 2 written references, criminal records bureau checks, health declaration, identification records, training certificates and application forms (these do not presently cover gaps in employment history and need to do so) a photograph on all staff files is also needed. There was no evidence to confirm staff are appropriately supervised between a Protection of Vulnerable Adults First and the receipt of a Criminal Record Bureau disclosure, this needs to be in place and information of how to do this and to meet the Commission for Social Care Inspection requirement is on the website. The manager confirmed staff have a contract, a job description and have received the General Social Care Council Code of Conduct as required. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 21 Recruited members of staff have received induction training within 6 weeks of appointment to their posts. The Annual Quality Assurance Assessment (the form all owners have to complete for the Commission for Social Care Inspection) states the Skills for Care Induction is used, there was no evidence of this but they may have been with the staff members themselves. 57 of care staff have a National Vocational Qualification in Care at either level 2 or level 3. The required number of trained staff required within a care home is 50 . All bar 2 staff are actively involved with a National Vocational Qualification. The home has a training matrix for all staff, this covers all mandatory training (2 staff require updating in moving and handling) the rest are in date until November 2007.Training in specialist care such as dementia is offered, this assures people who use the service that the staff have the skills and training to meet their needs. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Generally the management and monitoring systems in the home safeguard the people using the service. EVIDENCE: The registered manager Sandra Black has been in post for three years. Unfortunately, she has to retake the Registered Managers Award due to lack of information provided by the previous assessing body. People who were spoken to were happy with the manager and staff team and felt they were approachable. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 23 There is continuous self-monitoring within the home and the required regulation 26 visits are undertaken on a monthly basis. A quality assurance system is in place within the home, the Commission for Social Care Inspection advised the manager that the results of this need to be collated and shared with the people who use the service. Service users’ financial interests were safeguarded. There were views expressed by all parties that communication between the owners could be improved upon, one questionnaire revealed “Still trying to contact the owner to sort something out” Others said, “ They are in and out.” “ They don’t really ask us much, just are you happy.” A recommendation to look at further ways to improve communication was made. The manager is also in need of supervision, she has never been offered or received a structured timetable. A requirement to offer her the time to fulfil her role has also been made. The home should liaise with the fire officer to discuss completion of individual fire evacuation procedure and check present records are suitably robust. The manager needs to also confirm the safety of keys and locks used for bedrooms where the people who use the service request a key. The Annual Quality Assurance Assessment document completed by the home states the Health and Safety of the environment is regularly checked and action taken to keep the people using the service safe. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 24 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 2 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X 2 X X X 2 STAFFING Standard No Score 27 2 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 2 Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5(2) Requirement Mavesyn Ridware must supply a copy of the Service User Guide to each person who uses the service. This then enables people to understand what is available, how to complain, terms and conditions, the address for the Commission for Social Care Inspection and will assist people to make informed choices. People who use the service must be offered the appropriate support to meet their needs. The home must develop a programme to assess and monitor the staffs’ competency in administering medication to the people who use the service. A record of the maximum and minimum temperature of medication stored in the fridge must be recorded. Controlled drugs must be suitably recorded in a controlled drugs register. People who use the service and administer their own medication must complete an assessment and consent form. This is to DS0000004978.V339750.R01.S.doc Timescale for action 01/09/07 2 3 OP4 OP9 12(1)(a) 13(2) 21/08/07 01/10/07 4 OP9 13(2) 07/08/07 5 6 OP9 OP9 13(2) 13(2) 07/08/07 07/08/07 Mavesyn Ridware House Version 5.2 Page 26 7 OP12 16 (2m, n) 12 (4b) 8 9 OP15 OP16 13(3) 17(2) 10 OP19 13(4)(a) 11 OP22 23(2)(n) 12 13 OP26 OP27 13(3) 19 (1)(b) (i) 14 OP30 18(1)(c ) (i) 18(1)(a) 18(2) 15 16 OP31 OP31 17 OP33 24(2) ensure everyone’s safety and understanding. Activities and stimulation must be provided for all of the people using the service who wish to participate, including those with more complex needs to ensure a high quality of life for all the residents. Opened jars etc with a recorded expiry date must be labelled and dated. A record must be kept of all complaints made and includes details of investigation and any action taken. The sharps box, razors, enemas and other potential risks must be removed from the downstairs bathroom without delay. Any equipment or aid e.g. bed guards, must be individually assessed to make sure it is suitable for that individual. Hand sluicing does not comply with infection control standards and must cease. The home must ensure that the recruitment procedures are properly followed, this ensures all staff are suitably vetted to protect the people who use the service. All staff need to be trained in the moving and handling techniques necessary to support the people who use the service safely. The registered manager must be offered the required time to fulfil the responsibilities of her role. It was noted that the registered manager has not been in receipt of supervision and this is a requirement of the inspection. The results of surveys completed by the people who use the service need to be published and DS0000004978.V339750.R01.S.doc 01/09/07 07/08/07 01/08/07 08/08/07 08/08/07 08/08/07 01/09/07 01/09/07 01/09/07 01/09/07 01/10/07 Mavesyn Ridware House Version 5.2 Page 27 18 OP38 12(1)(a) made available to current and prospective users, their representatives The manager needs to check the suitability of bedroom locks where the people who use the service request a key. 14/08/07 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 OP1 Good Practice Recommendations The home should develop a more user friendly Statement of Purpose and Service User Guide to assist people who use the service with complex needs, including sensory impairments. The home should consider ways in evidencing equality and diversity within their service and how they support people with more complex needs. The care plan could be further developed in some instances. The temperature of the medical stock room should be considered because some medications may be being stored at too high a level. A new BNF should be purchased (dated 1999) to allow staff up to date information on prescribed medications. The home should return unused medication as soon as possible to eliminate excess stock. The manager and staff should explore further how they can enable the people using the service to make choices within their daily lives, including meals. The home should ensure people who use the service know what is on offer at mealtime. All daily cleaning tasks in the kitchen should be completed as per the homes policy The cook should liquidise all parts of a meal individually The home should repair or replace windowsills that are assessed as unfit. The home should consider providing alginate bags to support infection control standards in the laundry. The manager should liaise with the fire officer to ensure DS0000004978.V339750.R01.S.doc Version 5.2 Page 28 2 3 4 5 6 7 8 9 10 11 12 13 OP4 OP7 OP9 OP9 OP9 OP14 OP15 OP15 OP15 OP19 OP26 OP38 Mavesyn Ridware House the risk assessments around evacuation for the people who use the service are suitable. Mavesyn Ridware House DS0000004978.V339750.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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