CARE HOMES FOR OLDER PEOPLE
Mavesyn Ridware House Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB Lead Inspector
Mrs Wendy Grainger Unannounced Inspection 23rd January 2006 12:30 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.V276760.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.V276760.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 01543 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.V276760.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th September 2005 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 who 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. Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was commenced with the Deputy Care Manager and staff in the absence of the Care Manger who commenced duty later in the day. The Deputy Care Manger demonstrated her ability, competence and skills to conduct the inspection. Some of the residents were spoken with comments about the Deputy Care Manger and the staff on duty during the morning were that “they were excellent” “ look after us” Residents were finishing lunch at the commencement of this inspection. One resident told the inspector that she chose not to have a pudding. This inspection identified that the home had four vacancies; at times people wanting respite care took the placements. The activity programme remained limited residents told the inspector that activities took place only if the staff had time and that it was not a regular thing. There had been no newspapers provided on the day of the inspection. The progressive mobility provided had been postponed until later in the week. The partial tour of the home identified a good standard of hygiene. There were no malodours on the ground floor. Upon entry to the home the lounge fire door was held open by a chair, the door guard was inoperative due to the lack of a working battery. Three other fire doors were wedged open. The maintenance person at the suggestion and agreement of the Deputy Care Manger; removed a door guard from one vacant bedroom door and fitted it to another residents door. In the event a resident chose to have their door held open, then it is the registered persons responsibility to provide the appropriate equipment. Arrangements were in place for the continued health care of the residents. The system for medication remained the same there was an occasional “gap” in the recording of medicines administered. Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 6 Catering was based on a four weekly menu, during the inspection the required temperatures were evidenced; one of the freezer temperatures was over the guidelines on a regular basis. There was no evidence of the special diet provided for one person’s daily requirements. The toasters were in a poor condition, the trays underneath were full of crumbs evidencing that they had not been emptied. The fridge in the storage room was in urgent need of wiping out, two parsnips were handed to the Registered Care Manager to dispose of due to their condition. The heating in general was working. The small radiator in the conservatory however was not working, this area was used daily by residents, one resident in particular was in a blanket. Families also brought this to the attention of the management following their visit with their relative. Staff training could not be confirmed from the records provided. The matrix contained “ticks” and no dates. This record was not current for the staff employed. What the service does well: What has improved since the last inspection?
Following the previous inspection the providers had purchased a new fridge located in the kitchen. Within the dining room new tables had been purchased, they were fitted with cream tiles on the top. Dining room chairs had also been purchased, some of the older chairs remained to suit individual needs. Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 7 What they could do better:
Following the previous inspection (8.September 2005) and from records in the previous inspection report (17 January 2005) in respect of the staffing requirements the manager had continued to employ staff prior to having the required checks to comply with the law and legislation to ensure the safety of the residents. The provider and manager had been made aware that CRB checks were not transferable. One person had returned to work at the home in February 2005 she remained without a current CRB check. One person was working from 2pm until the following morning. These hours are excessive and need to be reviewed. If there were insufficient staff to cover the shifts then agency should be contracted. There was no evidence of the permit to work in respect of the recently employed staff from abroad. There was no evidence of the recently appointed staff receiving any induction training to provide care. Fire records were not available to ensure that each person had been involved in a fire drill since 2004. The manager was unable to locate the records. Evidenced from the records that the matrix used for staff training was not current a number of the staff had left employment. It is important that dates and not “ticks” were recorded to track training. There was no evidence of any alternatives to be or served for meals. No menu had been prepared for the person on a special diet. The toaster and fridge were in need of cleaning. It was suggested to the manager who agreed that they were unacceptable that the toaster should be part of the cleaning programme. Fire doors were wedged open, (four) including the lounge door, which had an inoperable battery in the door guard. The fire records identified that when the person responsible for testing was on holiday, no person had tested the fire system. This could leave the residents at risk. The radiator in the conservatory was not working, this area was used daily by the residents. One family informed the manager that they felt it should be looked at.
Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 8 On occasions the records for the administration of prescribed medicines had not been signed. A number of these issues should have been identified in the weekly/monthly checks of the systems and homes audits. 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.V276760.R01.S.doc Version 5.1 Page 9 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.V276760.R01.S.doc Version 5.1 Page 10 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 Standard six does not relate to this home. The Statement of Purpose was available; it contained information for someone to make a choice of placement. EVIDENCE: The Statement of Purpose remained unchanged, the document and the Service Users Guide were located in the front entrance hall. There had been no new admissions since the previous inspection. Assessments would be carried out in the event of a placement being requested. Mavesyn Ridware House DS0000004978.V276760.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 care plans had not been streamlined as suggested. Records evidenced that the plan seen was current. The system for the storage of medicines was satisfactory. The records for the administration were not current where staff had not signed. Arrangements were in place for the continued health care of residents. Staff on duty demonstrated their commitment to the personal care of the residents. EVIDENCE: The format of the care plans had been discussed as to benefit the staff in accessing the relevant details for continued care. The sample plan seen, evidenced that this plan had been reviewed. Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 12 The continued health care by other agencies continued on a regular weekly basis. The system for the administration of prescribed medicines remained satisfactory. The records identified that on occasions some of the staff had not signed when medication had been administered. The manager should have audited this. The staff observed on duty for the morning shift demonstrated that they were committed to the care of residents and competent in their role. Mavesyn Ridware House DS0000004978.V276760.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 records evidenced that there was no written alternatives for residents to choose from; this style of menu did not offer choice. Contact with families was maintained; the home had no restriction on visiting times. The programme for activities remained unchanged with limited involvement of external and in house social planning to suit residents. EVIDENCE: The manager had written a programme for weekly activities; residents told the inspector that activities were not regular and only when the staff had the time. External entertainment was limited; the progressive mobility had been put off until Wednesday due to the planned decoration of the large lounge. The record of activities had not been complied with following the last inspection. There was no evidence of stimulation for the more mentally frail residents.
Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 14 The meal of the day was chips, sausage, and egg, followed by bread & butter pudding. Assorted sandwiches and cake was prepared for tea. There were areas of concern with the menus that offered no alternatives. No written menu was evidenced for the resident on a Glutton free diet. The fridge in the kitchen and the fridge in the storeroom required cleaning. The freezer in the storeroom was constantly maintained at a temperature of 27o this was higher than the recommended temperature. Two parsnips were given to the Care Manager to dispose of, they were wrinkled and soft and not fit for use. The two toasters were not on the cleaning programme, this was evident with the quantity of crumbs in the trays at the base, this is a potential fire hazard; and pointed out to the Care Manager. Mavesyn Ridware House DS0000004978.V276760.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 home displayed the complaints procedure within the home and required documents. The training programme could not be confirmed or clearly evidenced from records, this could leave the residents at risk. EVIDENCE: The matrix for staff training was out of date with names of the staff that had left employment and not a current staff list. The manager “ticked” the boxes, which did not identify the dates training had been taken. The Deputy Care Manager thought her training was current and obligatory training should commence in February 2006. There was no evidence of Dementia training to meet and understand the needs of the three mentally frail residents and the residents who were forgetful. The Commission had received no complaints about the home or care provided. Mavesyn Ridware House DS0000004978.V276760.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): 19,21,24,26 The management and staff provided a clean and environment free from malodours. The problem remained with one of the bathing facilities, this may be harmful to residents and staff. Personal toiletry items were left in the bathroom, these could be hazardous to residents. A radiator that was out of order in the conservatory, left the area below a suitable temperature, residents were using blankets. The wedging open of the fire doors leave the residents at risk in the event of fire. EVIDENCE: Located at the end of a quiet lane and opposite the church, personal transport would be required to visit the home.
Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 17 The problem with the panel on the corner pink bath according to the maintenance person was addressed on a regular basis. The problem remains with the panel sticking out. This remains a potential hazard for residents and staff. The providers need to resolve the problem by an alternative method. Personal toiletries had been left in the bathroom, removed by the staff on request. Within the dining room the provider had purchased new tables and dining room chairs. The tables were a pale wood an insert of pottery tiles detracted from the homely ambiance of the home. Some of the original chairs remained to suit resident’s needs. Wallpaper in this room was damaged and required attention. There were plans to decorate the large lounge this had been put on hold from the previous two weeks. The Registered Care Manger told the inspector that she was unaware of the colours to be used. This provided the inspector with evidence of no consultation with the care manager or the residents. Four fire doors were wedged open, including the lounge door. It is important that this practice ceases; it is the providers responsibility to provide the appropriate equipment in the event of residents choosing to have their doors open. A vacant room fitted with a door guard was removed on the suggestion of the inspector and fitted to one of the doors held open. Mavesyn Ridware House DS0000004978.V276760.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): 27,28,29,30 Because of the no compliance with the required checks prior to employment, recruitment procedures leave the residents vulnerable. EVIDENCE: The inspector was concerned that the registered care manager had continued to employ staff without the required police checks. This practice was fully discussed during the inspection on the 17 January 2005. Two new night staff one from abroad had been employed; there was no evidence of induction, POVA first check CRB or work permit. The application of the person from abroad clearly stated that she was not able to work at the time due to an au-pair contract. One member of the present staff had returned to employment in February 2005. The CRB check on file was not acceptable. It was identified to the providers and the manager in the January report that the CRB checks were not transferable. The inspector evidenced from the rota that one person was on duty from 2pm until the following morning. These long hours could put residents at risk with staff not being effective to do their job. Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 19 The care manager told the inspector that this was occasional; according to the rota evidenced it is a regular occurrence. At the time of the inspection there were three staff on duty for the morning shift, replaced by three staff for the afternoon shift. The morning staff were supported by catering and housekeeping. The matrix used by the manager was out of date; staff that had left remained on the notice. There were no structured details for the obligatory training of staff. It was recommended that the care manager enter dates for training not “ticks” There was a requirement for staff to receive training in the care and awareness of Dementia, to meet the needs of the present group. Mavesyn Ridware House DS0000004978.V276760.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): 32, 36, 37, 38 The home had a relaxed atmosphere where the life style of residents by the staff was a priority. The safety of the residents could be compromised with out the full staff team not completing a fire drill/training. Staff confirmed that the homes manager continued with supervision. EVIDENCE: Staffs on morning duty were observed to respect residents as individuals, the routine of the home continue after lunch. Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 21 Staff confirmed that they had supervision; the manager told the inspector that supervision was accompanied with a staff appraisal. It was suggested that each one could be separate to achieve the best from each session. Records were stored in the office on the first floor with the exception of the fire records. During the previous inspection records identified that two staff had not been part of a fire drill. These inspection records after 2004 could not be located. The person responsible was on duty, as maintenance but could not locate any further records. On the occasion this member of staff has been on holiday testing of the system had not been undertaken. This practice needs to be reviewed, as residents could be put at risk without the essential training. There was a requirement for all the staff to receive obligatory COSHH training. Mavesyn Ridware House DS0000004978.V276760.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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X 3 3 2 Mavesyn Ridware House DS0000004978.V276760.R01.S.doc Version 5.1 Page 23 yes Are there any outstanding requirements from the last inspection? 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. 2. Standard OP9 OP12 Regulation 13(2) 16 n Requirement The registered person shall audit and ensure that medication records were current at all times 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 The registered person shall ensure that all parts of the home to which residents have access are so far as possible practicable are free from hazards to their safety. The bath panel on the pink bath was such a hazard and should be replaced or repaired. The registered person shall ensure by means of fire drills and practices at suitable intervals that the person working at the home are aware of the procedure to follow in case of fire including the procedure for saving life. The registered person shall ensure that records referred to in Schedule 4 in respect of fire are at all times available for
DS0000004978.V276760.R01.S.doc Timescale for action 01/02/06 01/02/06 3. OP21 13 (4) a 01/02/06 4. OP38 23 (4) e 01/02/06 5. OP38 17 01/02/06 Mavesyn Ridware House Version 5.1 Page 24 6 OP15 16 (i) 7 OP15 16(j) 8 OP18 18 (c) (i) 9 OP29 Schedule 2 (7) 13 (C) 10 OP38 inspection The registered person shall maintain the appropriate records of food served for special diets and any alternative offered on a daily basis. The person responsible shall make suitable arrangements for maintaining satisfactory standards of hygiene 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 The registered person is required to ensure that prior to employment POVA first and Criminal Record checks are made The registered person shall unnecessary risks to health and safety of residents are so far as possible eliminated 01/02/06 01/02/06 12/02/06 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mavesyn Ridware House DS0000004978.V276760.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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