Inspection on 01/03/06 for Maynell House

This inspection was carried out on 1st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Maynell House 18/09/09

Maynell House 30/05/07

Maynell House 29/09/05

Maynell House 30/03/05

Maynell House 30/09/04

Maynell House 17/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Maynell House High Road East Felixstowe Suffolk IP11 9PU Lead Inspector Deborah Seddon Unannounced Inspection 1st March 2006 10:00 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 Maynell House DS0000024444.V285063.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. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maynell House Address High Road East Felixstowe Suffolk IP11 9PU 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) 01394 272731 01394 272731 Pri-Med Group Ltd. Ms Wendy Jacqueline Patient Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2005 Brief Description of the Service: Maynell House is a care home registered to provide accommodation and personal care for up to 25 older people. The home is part of the Pri-Med Group Ltd and is one of the organisations’ three care homes for older people in Felixstowe. It stands back from the main road in it’s own extensive grounds. The house was once part of the independent boarding school for girls and it retains many of it’s original features, but has been extended to provide additional accommodation, including a pleasant veranda where residents can sit in warm weather. The home is on three floors and access to all but one room is either by staircase or a passenger lift. All rooms are tastefully decorated and furnished. There are two lounge areas and a dinning room. Interesting gardens surround the house, which includes a water feature complete with mature fish. Bedrooms are equipped with a single bed, wardrobe, chest of drawers, bedside cabinet and an easy armchair. With the exception of two rooms all have en suite facilities providing either a bath or a shower. Many of the bedrooms have views over the gardens. Residents are encouraged to bring their own personal possessions into the home, including small items of furniture. There is an emergency call bell system in operation situated in each bedroom and bathroom. The home is staffed 24 hours a day, with two waking night staff. The company has achieved Investors in People Award, initially in 1995 and has subsequently been re-accredited three times. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over three and quarter hours. The inspection focused on looking at the standards not assessed at the last inspection on the 29th September 2005. Therefore to have a true reflection of the home this report should be read in conjunction with the report from the September inspection. The manager of the home was on leave.Time was spent talking with the organisations training director, deputy manager, residents and staff. A tour of the premises was made and a number of records were examined including those relating to residents, staff, duty roster and medication. The inspector spent time talking with two residents and with two relatives and the district nurse who were visiting on the day of the inspection. What the service does well: What has improved since the last inspection? 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. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 6 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 Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: These standards were assessed at the last inspection and were found to be met. Therefore they were not inspected on this occasion. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 8 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): 7,8,9,11, Residents can expect to have their health and personal needs identified met and reviewed on a regular basis. Residents can expect to be protected by the home’s policy and procedure for safe administration of medication. EVIDENCE: The care plan of one resident was inspected. The care plans contained details of the resident’s health, personal and social care needs. They had detailed moving and handling and falls assessments completed, which assessed them to be a low score as they were able to move around independently with the aid of a Zimmer frame. Evidence was seen that the care plan was being reviewed on a monthly basis or more frequently if their health needs changed. The plan reflected they had been in hospital recently for an operation and was now recovering. The inspector spent time talking with the resident who confirmed that the information in their care plan was accurate and related to their needs. They told the inspector they were happy living in the home and with the service they received. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 9 The relatives of one resident arrived during the inspection. Time was spent with the inspector and the deputy manager discussing the general health and well being of their relative. They said they happy with the service being provided but were concerned that the relative had gained weight, which was contributing to mobility problems. The deputy confirmed that the resident had been weighed recently and according to records had gained 2 stone. However they agreed to re weigh the resident to check the weight and discuss with them a referral to a dietician for some advice for a healthier eating plan. The relatives were concerned that the increase in weight had been a contributing factor to a recent accident that the resident had where they had sat down heavily in their armchair causing the armchair to tip backwards. The resident had obtained a head injury. The wound was seen was seen to be healing well and the resident told the inspector they were having their stitches removed by the district nurse the next day. The district nurse arrived to see three residents. Two to have a blood test and the third a routine INR test. The district nurse was very complimentary about the staff and felt that the level of care provided to the residents was of a good standard. The district nurse said the staff are always available to help when they visit, which is helpful if the resident is unknown to the district nurses. The staff are good at contacting the district nurse team if they are concerned about any of the residents and consult with them for the provision of pressure relieving equipment. A requirement from the last inspection for prescribed lotions and creams to be signed for when they were administered has been actioned. There was evidence that creams are being signed for on the medication administration records (MAR) charts. Residents that self-medicate keep their creams in their own room in the lockable storage provided. A member of staff responsible for medication talked through the process of ordering, administering and returning out of date medication with the inspector. Medication is held in a locked cupboard next to the manager’s office. The order for the next month’s medication had been checked against current stock the day before the inspection, therefore there was minimal stock being held. The home uses the monitored dosage system (MDS). Medication for new residents was seen in their original packaging and labelled with the resident’s details. Their medication for the next month has been ordered in the blister packs. Any unused medication will be returned to the pharmacy. A returns book was seen which gave details of the drug, the strength, quantity and reason for return. A signature from the pharmacist evidenced this and two staff signed the medication administration records (MAR) charts indicating the medication had been returned. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 10 Currently there are two residents prescribed controlled drugs. Controlled drugs are kept in a separate secure container. The controlled drugs register showed that one resident takes Temazepam. The balance of medication was checked against the record in the register and was found to be correct. A recent incident reported to the Commission for Social Care Inspection (CSCI) of a medication error was investigated internally by a manager. As a result of the investigation the training director arranged for all staff to attend refresher medication training. Additionally each member of staff has been given a workbook to complete and they have to provide a written statement of what they have learnt. Each of the staff involved in the error have had a recorded supervision session The home has had a number of residents that have sadly passed away in the last few weeks. Evidence was seen that residents were being supported to pay their respects to their friends. One resident spoke fondly of a resident whose funeral they were attending the following day. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed at the last inspection and were found to be met and therefore not inspected on this occasion. They will be reviewed in full at the next inspection. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 12 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): 17, People living in the home can expect to have their legal rights respected. EVIDENCE: Standards 16 and 18 were looked at during the previous inspection and were found to be met. Residents have the opportunity to participate in their civic right to vote. The majority of residents at Maynell House are able bodied and choose whether they wish to go to the polling station or to complete their vote by post. The deputy manager told the inspector that all of the current residents have families that are actively involved in their relative’s care and have not needed the services of an advocate. The training manager informed that inspector that other Pri-med homes have used advocates in the past and if a resident at Maynell needed this service the home would support them to access an independent advocacy service. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 13 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): 22,25, Residents can expect to live in a home that provides safe and comfortable surroundings, although there are some concerns about storage of equipment, which is to be explored with the fire service. Residents can also expect to have specialist equipment they require to maximise their independence. EVIDENCE: A tour of the building was made, it was a very cold day and the home was found to be warm and comfortable for residents. A requirement from the previous inspection for the home’s manager to assess the risks of residents scolding themselves on uncovered radiators has been actioned. Radiator covers have been fitted throughout the home and these have been nicely made to blend in with the interior decoration of the home. Only one radiator has not been covered as the size of the cover posed an obstacle and a risk to residents. The radiator is permanently turned off as there is a wood burner in the corner of the room providing warmth. The wood burner has a surrounding hearth and is not a risk to residents. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 14 Concerns were raised with the deputy manager about the storage of wheelchairs and equipment in the corridors. The corridors were escape routes leading to fire exits. The deputy had the chairs moved during the inspection, however consideration needs to be given to providing adequate storage for aids and equipment when not in use. The organisation’s training manager informed that inspector that they were having a visit from the fire brigade on the 6th March to carry out an inspection of the premises and would discuss the safety issue of storing wheelchairs in the corridors. Evidence was seen in resident’s rooms, bathrooms and in communal spaces that equipment is provided to enable residents to maintain independence and mobility. A recliner chair electrically operated to assist the resident to standing was positioned in the lounge overlooking the garden. The deputy showed the inspector a bathroom, which has been refurbished and they were having a new assisted bath delivered during the inspection. One resident told the inspector that they were finding it more difficult to walk and that they were considering purchasing an electric powered wheel chair to help their mobility. A company was visiting on the day of the inspection to assess the resident’s needs. The resident was observed later in the morning having a trial session in a wheel chair and was able to operate the controls to navigate their way along the corridor and into the lift. The corridors are wide enough for the resident to access all areas of the home and they were seen using the lift to the upper floor to return to their room. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 15 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): 27,30, Residents can expect to be supported by a staff team in sufficient numbers that have received training and support and have the knowledge to care for them. EVIDENCE: The staff rota was seen and reflected the number of staff on duty. The staffing ratio remains the same and showed that there were 4 staff working between 82pm and 3 staff working between 2-10pm with 2 waking night staff between the hours of 10pm and 8am. A new member of staff was working supernumerary as part of their supervised induction. The rota is used as a working document and reflects the actual hours, training, holiday’s and off duty. The rota also shows where staff are allocated time to complete designated duties, for example a member of staff was given time to sign in and account for the monthly medication order. The home has it’s own training package for all staff which is similar to national vocational qualification (NVQ) incorporating 4 levels. The training is “hands on” learning approach and all care and ancillary staff are encouraged to take part in their own learning and development. The inspector discussed with the training manager how the new skills for care induction standards would fit in with their existing training. The training manager felt that the new standards would fit in with the current two week rolling programme. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 16 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): 33,34,35,37,38, Residents living at the home can be assured that suitable financial and accounting procedures are in place and that their financial interests are safeguarded. Residents can be assured that the home is run in their best interests and are protected by the home’s procedures for health and safety. EVIDENCE: Pri-med has an effective quality assurance monitoring system. The most recent quality assurance report for the period August 2004 to July 2005 was copied to the Commission for Social Care Inspection (CSCI). Feedback was obtained from residents, staff and external agencies. The results of the quality assurance survey were very positive about the service and showed a reduction in accidents, staff turnover, staff sickness and complaints. The report reflects that the quality monitoring is used to form the basis of the overall business plan and is undertaken annually. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 17 The home has developed their own action plan. This is reviewed by a steering group made up of the manager and staff and discussed at residents’ meetings. The training manager informed the inspector that the action plan is reviewed on a regular basis and is linked to the budget. The aim is to ensure that the home is run in the best interests of the residents and to be the best home for older people with in the area of Felixstowe. The action pan for January 2006 was seen and evidence was seen that some of the objectives had been met in line with the completion dates. For example an area highlighted as a concern was food hygiene. The training manager has completed an advanced course in food hygiene and will be training all staff in house to comply with the new food safety standards introduced in January 2006. Evidence was available to indicate that residents are safeguarded by the accounting and financial procedures of the home. The income and expenditure accounts seen for the year 2004-2005 were seen and reflected that the home is running on its current budget and meeting the forecasted expenditure. Evidence was seen that the home has liability insurance cover against the loss or damage of the business and public liability. The insurance expires in June 2006. Residents that are able to manage their financial arrangements themselves are encouraged to do so and are provided with lockable space in their rooms to keep valuables and money. Other residents’ monies are held on their behalf in a safe. The inspector was shown that monies are held separately supported by a running account, which is held for each resident with receipts attached to provide an audit trail of expenditure. The records and balance for one resident was checked and found to be accurate. Maynell House has a range of procedures. These are accessible and held in the manager’s office with the personnel records relating to staff and residents. These are kept safe and secure. Residents and staff have access to their files on request to the manager or the deputy manager to safeguard the confidentiality of personal information held about them. Records relating to incidents and accidents that occur in the home are kept. A copy is taken of the completed form and the original is sent to the Pri-med head office for auditing. When the original is returned the copy is destroyed and the original filed. An audit of accidents is kept and a graph showed an increase in accidents in June and September 2005. The records showed this was due to four residents having re-occurring falls. Risk assessments have been completed and were attached with the accident reports highlighting the areas of risk and how these are managed. The health, welfare and safety of residents and staff are protected by the home’s procedures for maintaining and undertaking periodic checks of systems and equipment. For example a schedule of regular checks undertaken by the maintenance person included hot water checks, ensuring that the fire alarm system is tested, manual check of appliances and maintenance of the boilers. Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 18 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X X 3 X X 2 X STAFFING Standard No Score 27 3 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 3 3 X 3 3 Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 19 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 OP25 Regulation Requirement Timescale for action 31/03/06 13,4,a,23, All parts of the home must be 2,l free from hazards for the safety of the resident’s and suitable provision made for storage of wheelchairs and equipment so that they are not stored in corridors which are fire exit routes. 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 Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maynell House DS0000024444.V285063.R01.S.doc Version 5.1 Page 21 - 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. 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