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 19 April 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.V290240.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. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 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.V290240.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd January 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.V290240.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was completed over two days; the home had received a completed a pre-inspection questionnaire prior to the visit. Evidence presented in this report was accumulated from relatives and residents comment cards, verbal comments from the visiting district nurse and two relatives, providers and residents spoken with over the visit, in addition to direct observations by the inspector. Records documents and reports were also collated for the report. What the service does well: What has improved since the last inspection?
The pre-inspection questionnaire provided identified that the providers had purchased a new microwave, and large cooker. The large lounge had been decorated as have two bedrooms; bedrooms where necessary had been recarpeted and new furniture had been purchased.
Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 6 Three new staff had been employed and the required checks had been completed. The previous inspection report identified ten requirements, from information gathered during this inspection some requirements remained unaddressed; other requirements had been addressed satisfactorily. Some limited staff training had been arranged. Since the previous inspection the requirement to obtain the appropriate information and checks prior to employment had been complied with. What they could do better:
At the time of this inspection the person responsible had failed to respond to all of the requirements; the time scale given had expired on 01/02/06 & 12/02/06, this included staff training to care for people with a dementia and the obligatory COSHH training. The need for this type of training was to enhance and improve the lifestyle of the six residents with a dementia; to provide the staff with the appropriate knowledge to care for and stimulate the residents. Prior to the inspection the inspector was aware that staffing levels had been reduced to two staff on the afternoon shift from the 01/04/06. With the dependency of the residents both physically and mentally this staffing level left residents at risk. The staff were expected to continue with the residents personal needs i.e bathing, they were expected to prepare tea when a hot tea was planned on alternative days, answer the phones and turn one person on a regular basis. Following the commencement of the first day’s inspection the providers agreed from discussions to reinstate the three staff on the afternoon shift from the 20/04/06. One of the comments cards received from a relative identified that the family were not welcomed to the home by the owners/staff, see their relative in private, not kept informed about their relative, insufficient staff on duty and that they were less than satisfied with the care provided. There was no internal evidence of the home’s quality assurance system with the exception of a policy. One of the senior management in Manchester was spoken with in respect of the quality assurance and the required feedback from the appropriate sources. Staff should be aware of the procedure to administer medication to the person identified on the prescription. The Statement of Purpose lacked any evidence of the registered care manager and the staff information could be clearer. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 7 The care plans remain unwieldy for the staff to use; advice was given as to streamlining them to ensure they are active “live” plans. To protect the residents in the event of a fire, the equipment provided should be in working order at all times. 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. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 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.V290240.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 Standard six is not relevant to the home and care provided. The quality in this outcome area is poor; this judgement has been made using evidence available at the time of the two inspections. The Statement of Purpose would not provide the required information to members of the public seeking a placement. The home’s pre-assessment system remained unchanged and satisfactory. EVIDENCE: From the information gathered within the Statement of Purpose document, the inspector identified that the information contained in the document would not provide any prospective resident or their family with appropriate information in respect of the registered care manger. Within the care records seen during the inspection each record contained the pre-assessment made prior to admission.
Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 10 It was the practice of the home to offer an invitation to any prospective person and or their families prior to accepting a placement. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality of this outcome area is poor. This judgement has been made using available evidence including visits, reviewing systems and records. The staff were evidenced to be caring competent and provided sensitive care to residents. There remained concerns regarding the lack of staff training to stimulate the people with dementia. Despite staff training the medication system identified poor practice with medication. Care plans remained undeveloped and unwieldy for the staff to use effectively. EVIDENCE: There had been no further development of the care plans and for the streamlining recommended in the previous inspections. The care plans were “not active/live” they contained duplicated documents, which in some cases made the documents unwieldy for the staff. Three plans were evidenced and the results fed back to the care manager.
Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 12 There was no written evidence of the residents being involved in setting up and or reviewing the care plans; two of the residents when speaking to them confirmed this. There was evidence of staff not entering dates as to when reviews had been completed. Within one care plan there was little evidence of how the resident with dementia needs were met. Training for the care of people with dementia had been made a requirement in the inspection report of January 2006; no plans or time scale were projected at the time of this inspection. Medication continued to be stored off the main corridor. From the examination of the records there had been an improvement in the recording; staff had endeavoured to sign for the medication given; the previous report required the manager to audit the system to ensure no “gaps” occurred. Further advice was given for checking medication when it was delivered to the home. There was a requirement identified to the care manager that medication prescribed for residents no longer at the home should be disposed of; and that any prescribed medication should only be used for that individual and not indiscriminately for other residents. Arrangements were in place for the health care of the residents to continue where applicable. The visiting district nurse was very complimentary about the staff ability to provide appropriate care for individuals. During the time spent at the home the inspector evidenced the staff meeting the personal care needs of individuals. The staff were competent caring and were aware of the need to respect individuals choice, assisting where necessary. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 The quality in this outcome area is poor. This judgement has been made using available evidence gathered from the people using and operating the service. Resident activity/stimulation because of the low staffing levels did not provide all or any of the residents with any form of a social lifestyle. This included staff training to meet the registered category for dementia. At the time of the inspection there were alternatives offered for the main meal of the day. EVIDENCE: From the evidence and from comments by the residents and staff the activities at the home were virtually non-existent. There had been a reduction in the afternoon staffing levels since the 1/4/06 this had prevented staff doing the proposed activities, which were usually planned for the afternoon. The previous inspection report made a requirement for residents to be consulted about their preference, interests and hobbies. This had not been addressed. During the second visit when the staffing level had been increased to the required three staff, staff were observed to be playing “Bingo” with three of the residents. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 14 While the home had a number of games available the manager needs to be promoting stimulation, interests for the less able residents in meeting their needs in a proactive manner. An option of visiting at any time convenient to the families and friends was observed. The meals provided appeared satisfactory to the residents spoken with after lunch. Staff were very aware of the options of combination of food required by certain residents. Each person was asked his or her choice of the two main items on the menu. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 15 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 quality in this outcome is adequate. This judgement has been made using available evidence including speaking with the management and staff. Some limited training had commenced, the experienced staff were aware of the process to raise concerns, they had however not had accessed the written guidelines. EVIDENCE: From the evidence gathered by speaking with the staff and manager, no person had read or accessed Staffordshire’s Vulnerable Adults procedure. The procedure was located in the home’s policies. Staffs spoken with were aware of the process to engage if any form of abuse was suspected. The manager had commenced a training document Recognition and Prevention of Abuse. Each member of the staff will be expected to read and answer the questions. It was recommended that all the staff read and sign the Vulnerable Adults policy. The complaints procedure was displayed in the appropriate documents and available to visitors, staff and residents. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 The quality of this outcome is adequate. This judgement has been made using available evidence, including first hand experience of the fire system activating. The two inoperable door guards could effectively put residents at risk in the event of a fire. The home, with the exception of the fabrics in the toilets referred to, was maintained to a high standard. The condition of the radiators remained unchanged since the previous inspection (January 2006) the problem had not been addressed to actively ensure the appropriate heating was provided. EVIDENCE: During the first part of the inspection, the fire alarms activated two of the door guards were out of order, one being the kitchen door, failure with the guards could put residents at risk.
Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 17 The radiators in the conservatory were still inoperable following the visit in January. The providers had provided alternative heating with two freestanding heaters. This problem on the day of the first inspection was passed onto the plumbers. The condition of the pink bath had improved; the bath panel had been secured. The two main toilets off the corridor had an odour of urine; while the internal environment was well maintained it could possibly be that the odour was coming from under the vinyl flooring. The remaining areas seen within the home were well maintained by the housekeeping staff. The providers continued to refurbish, decorate and upgrade where necessary. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 18 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): 27,29,30 The quality in this outcome area is poor. This judgement has been made using available evidence including access to records, speaking to management and staff. The requirement for obligatory staff training made on the previous inspection had not been complied with. Reduced staffing levels in the afternoon identified that residents social needs were curtailed. The dependency of the residents took a priority. Staff continued to offer the appropriate personal care. Staff employment requirements had improved since the previous inspection report. EVIDENCE: From the rotas there was evidence of the staff team being reduced to two for the afternoon shifts. This had occurred on 01/04/06. Following the first inspection visit and staff meeting this level had been increased to three staff, this level of staffing was adequate for the residents’ dependency needs. The morale of the staff was low. The experienced staff recognised that the staff reduction had left them with an impossible role as carers, catering and incharge for eight hours. The employment of staff, which was a requirement in the last inspection report had been complied with as evidenced from the records.
Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 19 There remained some issues regarding the obligatory training of staff, the person responsible for training was spoken with during the inspection; some training had been planned. It was agreed that the required training will be planned as soon as possible. Staff observation over two visits identified that the staff on duty were competent and skilled to meet the residents needs. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 20 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): 31,32,33,35,36,38 The quality in this outcome area is poor. This judgement has been made using available evidence including access to records, speaking to staff and senior management. No written evidence of the quality assurance system and feedback of the internal survey was made available. Training for some obligatory training was out of date. There had been some improvement in the records and fire awareness training for the staff. EVIDENCE: The registered care manager had not received the confirmation following the completion of the Registered Managers Award. The residents live in a relaxed style home; the frailer residents tend to be located in the large lounge, with the more alert residents tending to sit by choice in the conservatory.
Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 21 There has for sometime been no written evidence of the quality assurance system for the home with the exception of a policy. On each visit to the home the inspector was informed by one of the senior management that relatives surveys have been issued with limited or no response. There were no internal surveys, or stakeholders’ response. This report makes it a requirement for this standard to be more proactive in obtaining feedback on the quality of the service provided. Residents finances were sampled at random and found accurate. Some staff training had been undertaken for the procedure to be taken in the event of a fire. Notwithstanding this one person during the impromptu fire drill when the alarms activated did not respond. This was taken up with the manager the following visit. Records for fire awareness had improved, as had the training programme. Records for staff training identified Emergency First Aid 2005 Food & Hygiene 2005. The First Aid training was required to be undertaken again the timescale for this qualification is only twelve months. Staff confirmed that supervision was ongoing; records were maintained. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 22 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 X 3 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 1 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 2 3 STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 2 Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 23 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 OP12 Regulation 16 n Requirement Timescale for action 12/05/06 2. OP7 15 (1) 3. OP1 4 (c) 4. OP9 13 (2) The registered person shall consult residents about the programme of activities arranged by or on behalf of the care home. To maintain a record of events This requirement is outstanding from the inspection report of January 2006 (01/02/06) The registered person shall 12/05/06 ensure that the resident and/or representative are consulted in respect of their health and welfare. There should be evidence of the consultation on the care plan. The registered person shall 12/05/06 compile in relation to the care home a statement as to the matters listed in Schedule 1 The registered person shall take 01/05/06 the responsibility for medication and ensure that any medication not required is returned to the pharmacy after seven days waiting time. Medication should only be administered to the person it was prescribed to. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 24 5. OP27 18 (a) The registered person shall ensure at all times that the staffing levels are consistent to meet the residents personal, health and welfare needs The registered person shall ensure that there is written evidence of any special diet prepared on a daily basis for residents The registered person shall take adequate precautions to ensure that the equipment provided was in working order at all times to protect the residents in the event of a fire. The registered person shall having regard to the size of the home ensure that person employed at the home receive training and supervision appropriate to the work they are to perform. This requirement is outstanding from the inspection report of January 2006 (12/2/06) The registered person shall establish and maintain a system for reviewing at appropriate intervals the quality of care provided at the care home. 01/05/06 6. OP15 16 (i) 01/05/06 7. OP25 23 (4) (a) 01/05/06 8. OP18 18 (c) (i) 23/05/06 9. OP33 24 12/05/06 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 OP18 Good Practice Recommendations For all the staff to read Staffordshire’s Vulnerable Adults Procedure and to maintain evidence that the document had been read. Mavesyn Ridware House DS0000004978.V290240.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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