CARE HOMES FOR OLDER PEOPLE
Mavesyn Ridware House Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB Lead Inspector
Mrs Wendy Grainger Key Unannounced Inspection 12 December 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 Mavesyn Ridware House DS0000004978.V324103.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.V324103.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.V324103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: Mavesyn Ridware is a detached home standing in its own grounds overlooking the countryside. The home was off a public transport route and would require personal transport to access the home. Located near to the village of Armitage and Handsacre. The home retains some of its original features. Registered to provide accommodation to twenty-one older persons, six of whom may have a recognised dementia and six of who may have a physical disability. The home had one large lounge and one conservatory, service users personal choice was respected, and these people remained in their bedrooms. The dining room overlooks the garden and was well presented. The laundry and kitchen were located central to the home. Mavesyn Ridware has very limited parking space at the front of the home. Bedrooms were for single occupancy, some bedrooms had an en-suite facility; access to the first floor can be via the stairs and shaft lift. The monthly fees for the home vary from £347 for a basic bedroom - £367 for an en-suite bedroom this information was current from the 18 April 2006. There would be additional charges for personal newspapers, transport to hospital with an escort, hairdressing and chiropody. This information was part of the admission process. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This second key inspection was completed on the 12 December 2006. Staff, management and residents were instrumental in providing the information for the report. A sample tour of the home, records, reports and documents were made readily available. No resident questionnaires had been sent to the home. No family member or professional agency was seen during the inspection. What the service does well: What has improved since the last inspection?
Following the last inspection on April 19 2006, the upgrading of the home continues with new flooring in the ground floor toilets, this has eliminated the slight odour evidenced previously. Two bedrooms have been decorated and two bedrooms have had new carpet fitted. It is planned according to one of the providers spoken with during the inspection to decorate the front entrance. The nine requirements identified on the previous inspection had been addressed with the exception of number 2 which, still requires more work to improve the content of the care plans. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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 Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good standards inspected 1,3. This judgement has been made using available evidence including a visit to this service. Including sampling documents and by speaking to staff and management The statement of purpose provided the relevant information to enable a person to make a choice of home. No person was admitted to the home without an assessment of his or her personal and health needs. EVIDENCE: The previous inspection identified that the statement of purpose was not current in its information. The registered manger had reviewed and updated the relevant information. A sample of plans identified that any new person had been assessed prior to admission.
Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate standards 7,8,9,10 This judgement has been made using available evidence including a visit to this service. Reviewing systems, records and staff observation. Care plans have been made less unwieldy. There was still need for management to review and improve the contents in some sections. Care staff demonstrated their commitment to the care of the residents. The medication system had improved following the last inspection. Arrangements were in place for the continued health care of residents. EVIDENCE: The care plans had been streamlined, staff comments that they were easier to manage. There were sections i.e. medical history and medication plus social area where more detailed relevant information could be made to ensure staff were aware of all aspects of care. To quote the six principles of care does not constitute as adequate information in the social care section.
Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 10 The management need to review the daily reports to ensure that all the relevant details and information was continuous. To report that someone was “fine” on a daily basis is not sufficient, daily reports should reflect the daily routine. The records for medication had improved; the home had recently changed pharmacy and was waiting for an audit of the system. Records were complimented with a photograph of each resident. The management now check the medication in a sign to confirm accuracy. Staff had received training. It was a requirement that the two new staff receive formal training before administering medication. Arrangements were in place at the time of the inspection to address the health needs for three residents. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate. Standards 12,15 This judgement has been made using available evidence including a visit to this service. Speaking to residents, reviewing menus and food stored. Activities appeared to have improved, there remains no evidence of activities for the diverse needs of individuals. There needs to be a monitoring of food supplies to ensure that food is rotated and used in date order. EVIDENCE: The diary evidenced that some more stimulation was being provided for residents. Residents confirmed that they had been out to the Zoo in the summer. Residents should have attended the local school for a Christmas play at the time of this visit; due to the lack of transport residents were unable to go. There remained no evidence of a social life style and activity/stimulation for the residents with diverse needs. The menus were seen the meal today had been changed because there was no chicken in the freezer. Menus identified that on a number of days within the month beef or a derivative of beef was served.
Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 12 On occasional days the record of food served was left uncompleted. As were occasional days for the fridge/ freezer temperatures. A three week menu was evidenced for the resident on a special diet, the cook told the inspector that this resident had had fish with parsley sauce. Within the cool room it was identified that packets of food had not been rotated and were out of date; these were handed to the deputy care manager who disposed of them. Residents spoken with after lunch told the inspector that they had enjoyed the meal. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good standards 16,18 This judgement has been made using available evidence including a visit to this service. Checking documents and records. The statement of purpose and other relevant documents were accurate to enable any person to raise a complaint with the home or Commission. EVIDENCE: From evidence identified that the complaints process was available to person entering or living in the home. A requirement was made for all the staff to have access to the Vulnerable Adults policy. This had been activated and continued. The commission for social care had not received any complaint. Staff on duty were aware and would activate the complaints process if necessary. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good standards 19 20 21 23 24 25 26 This judgement has been made using available evidence including a visit to this service including a partial tour of the home. The home was maintained to a good decorative and odour free standard. The concerns raised in the previous inspection had been addressed. EVIDENCE: Residents live in a comfortable home, the rolling programme for decoration continued with areas being decorated and new carpets fitted. There were plans to re-decorate the front entrance. The housekeeping staff maintain a good standard of hygiene. The ground floor single toilets identified that open toilet rolls were sited on the cisterns, this is not acceptable; toilet rolls to prevent cross contamination should be covered and or in the containers provided. This practice should cease.
Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 15 The home was warm and radiators seen were operable. The conservatory remained with additional heating of a free standing heater. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate Standards 27 28 29 30 This judgement has been made using available evidence including a visit to this service, access to records and documents speaking to the staff on duty. There had been a marked improvement in the training programme, residents were less vulnerable with knowledgeable experienced staff. EVIDENCE: The rotas evidenced that the staffing levels remained unchanged and appeared satisfactory to meet the needs of the residents. At the time of the inspection the home had only two vacancies for a placement. A large commitment had been made by the providers and the staff to ensure that all obligatory training was current. Further training for 2007 was planed for dementia, this needs to include caring for diverse needs. Two new staff records were checked both had POVA only one had a CRB to confirm she was suitable to work with vulnerable people. One person had been employed since August. It was a concern that the registered care manager had not followed this up before the inspection. This was discussed with the manager. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 31 33 36 38 This judgement has been made using available evidence including a visit to this service. Including reviewing documents, records and speaking to the staff. Management provided evidence of the quality assurance system in operation. Fire records were in general satisfactory. EVIDENCE: The manager was able to evidence on the day of the inspection the quality assurance, two comments made by other professional agencies and stakeholders need to be further explored by the manager in respect of minor unfavourable comments. Residents in general were satisfied with the care they received. It was evident that some residents would enjoy a more social life with outings into the community.
Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 18 Records for the fire practice and training were generally satisfactory. The two new staff had not been part of a fire drill or training since commencing employment. These two staff covers night duty. It is most important to arrange training for these staff. Within the fire assessment there needs to include contingency plans. This was discussed with the care manager later. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 20 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 OP9 Regulation 18 (c) Requirement Timescale for action 01/01/07 2 OP15 16 (c) 3 OP29 Schedule 2 The registered person shall ensure that the new staff employed receive the appropriate training to administer medication until that time they should refrain from the practice of administrating medicines. The registered person shall 01/01/07 ensure by the rotation of food products that unnecessary risks to the health of residents are protected at all times. The registered person shall 01/01/07 follow up the criminal record checks for the new employee Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 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. 2 Refer to Standard OP7 OP38 Good Practice Recommendations To review the care plans and daily reports to ensure that they were relevant to provide significant information about the residents The registered person shall ensure that the two new employees have received training in respect of fire prevention and drills. Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Mavesyn Ridware House DS0000004978.V324103.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
