Inspection on 01/02/07 for Melbourne Home

This inspection was carried out on 1st February 2007.

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

Melbourne Home 05/01/09

Melbourne Home 06/12/05

Melbourne Home 07/09/05

Melbourne Home 11/02/05

Melbourne Home 15/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Melbourne Home 263 London Road Leicester Leicestershire LE2 3BE Lead Inspector Susan Lewis Key Unannounced Inspection 9:45 1st February 2007 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 Melbourne Home DS0000006441.V328779.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. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melbourne Home Address 263 London Road Leicester Leicestershire LE2 3BE 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) 0116 270 6771 0116 270 0682 Melbourne Hall Home Trust Deborah Edwards Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of service. Date of last inspection 6th December 2005 Brief Description of the Service: The fees for 2006/07 are from £345 to £407 A copy of the most recent inspection report can be found in the entrance hall. Melbourne Home is a large three storey Victorian building situated on the corner of London and Springfield Road. The home is set in pleasant well kept grounds which are easily accessible to service users. The home is close to a range of facilities and services. The home can accommodate up to seventeen older people in very spacious, well-equipped single rooms. Rooms are available on all three floors. All floors are accessible by lift. The communal areas of the home are comfortable and homely. There is a large lounge and additional sun lounge and dining room, together with a veranda on the first floor. The Home is owned by a charitable trust and describes itself as a Christian residential care home. The Home organises in house religious services every week, which is generally appreciated by service users. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records, talking with them where possible, and observing staff that provide their care. The inspection was unannounced and took place over 7 hours one Thursday in February 2007, and was conducted by two inspectors as part of the annual inspection process. The registered manager was not on duty but the person in charge assisted with the inspection. A partial tour of the building took place and a selection of residents’ bedrooms were inspected. residents’ and staff records were inspected and visitors, residents and staff on duty were spoken with. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: Residents live in a homely well-maintained environment, which meets their cultural and spiritual needs. Staff are trained and employed in sufficient numbers to meet residents’ care and health needs. Residents spoken with were positive about their experience of living in the home and made comments such as, ‘I don’t think you get any where better’. ‘Everything is there for the asking’. ‘If you are not keen on the meals they will always provide you with an alternative’. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 6 Visitors are made to feel welcome and are able to have a midday meal with their loved one if they want to. One visitor commented that she had observed that residents were respected and that their dignity was maintained. What has improved since the last inspection? What they could do better: Overall the home is well run and residents are well cared for. The Registered Person must ensure that where possible residents or their representatives are involved in the creation and review of their care plans. It is recommended that care plans be written in more detail to ensure that carers know exactly what to do and the residents’ wishes regarding their care. Although most residents are weighed there are no facilities to weigh residents who are non-weight bearing. It is strongly recommended that the Registered Person make alternative arrangements to ensure that all residents are weighed regularly. Some activities do take place and evidence was seen that some are planned for the better weather, however it is not always clear what activities take place in the home, it is therefore recommended that the Registered Person create a system of recording the activities that residents take part in and who takes part to show what variety is available and their effectiveness for residents. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 7 Staff receive instruction regarding recognising adult abuse during supervision, as not all staff were aware of the whistle blowing policy it is recommended that the manager include this topic in staff supervision to ensure all staff are up to date with these procedures to protect residents. Evidence was seen that POVA first is obtained for staff, however it was not clear who each email referred to and it is recommended that a system is devised to link each email to the member of staff to ensure that records can be checked effectively. 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. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents are assessed and that their needs will be met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were viewed for the purpose of this inspection. Each plan had an assessment from social services and a less detailed in-house assessment. The assessment was used to inform the care plan ensuring that the residents assessed needs were met. The service does not provide intermediate care. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Residents health and social needs are set out in a plan. Their assessed health and social care needs are met and they are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although each resident had a care plan that covered their assessed needs they were not always very detailed, however in discussion with staff it was clear that residents care needs were discussed in detail at each handover as it was seen as a working tool and so minimised any risk of missing any particular needs a resident may have. There was evidence that plans were reviewed, however there was no evidence that residents were involved in this process. Residents spoken with were not sure if they were involved or not, one resident was aware that a care plan Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 11 existed but not that it had been reviewed, another resident said that staff did talk to her about her care. It is required that the Registered Person ensures that where possible residents or their representatives are involved in the creation and review of care plans. It is recommended that this is evidenced to show that it is being done. Diary notes and records showed that GPs were called when residents needed to see one and residents confirmed that they saw their doctor when they wanted to. Evidence was seen that where residents were at risk of pressures sores that appropriate equipment and advice was obtained to minimise the risk. Residents spoken with commented, ‘The staff look after us well’. ‘If you don’t feel well the doctor is called and visits’. ‘The staff are kindness itself’ Evidence was also seen that residents were weighed regularly to ensure that their nutritional intake was maintained. However as the scales were only the stand on variety any resident who was not weight bearing could not be weighed. It is recommended that the Registered Person make alternative arrangements where this is the case. Medication is stored appropriately, only trained staff administer medication and staff were observed following the homes medication policy and procedure to ensure residents receive the correct medication at the correct time. Records showed that there was a clear audit trail of medication coming into the building, being administered or being disposed of. This ensures that all medication is accounted for. Residents were observed to be clean and well groomed, staff were observed through out the day speaking to residents with respect and care. A visitor said that she had observed staff knocking on doors and treating resident with respect and maintaining their dignity. Residents spoken with confirmed that staff were always kind and caring. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents have their cultural and spiritual needs met and it matches their expectations. Residents are able to exercise choice and control over their lives. They receive appetising and nutritious meals in a pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seven residents were spoken with in total and all said that they were happy and content living in the home. They were able to attend their local church or when the visiting pastor came to the home go to his talks and service. Residents felt that their spiritual needs were met and were happy with the arrangements. There was information posted on a notice board about when speakers came to the home. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 13 The Residents Meeting minutes also indicated that activities were to start in discussion with residents it was clear that some activities had started such as a word quiz that took place the previous day. However most residents commented that not much happened during the day but they were aware that an exercise class was due to start soon and that when the better weather came they would start going out on trips. Some limited information was on a notice board. It is recommended that the Registered Person record who takes part in the activities and to show what is being offered to residents throughout the week. Residents said that they were able to see their visitors when they wanted to and visitors confirmed that they could come to the home any time and were offered a meal if they wanted. Residents said that they felt they could control their lives and make choices about how they spent their day, residents confirmed that they were encouraged to bring in personal possessions to the home and bedrooms viewed showed that they were decorated in a personal manner. The midday meal was observed and it appeared appetising and nutritious. A choice was offered and residents confirmed that if they didn’t like the choice something else would be given. The cook was aware of the importance of maintaining the nutritional intake of residents and ensuring those residents with special dietary needs were supported including diabetics and those who needed a soft or pureed diet. Staff were observed assisting residents discreetly and asking them if they wanted help rather than just taking over ensuring residents dignity. Aids and equipment such as plates with lips on were provided to ensure that residents remained as independent as possible for as long as possible. Most residents chose to eat in the dining room but evidence was seen that residents could eat elsewhere if they chose to. Residents spoken with commented, ‘ You get plenty of food and if you are not keen on something then you always can have an alternative’. ‘The food is very good, you get plenty of it and there is a choice’. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Residents and relatives feel confident any complaints will be dealt with effectively. Residents feel safe and staff mostly understand how to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has not received a complaint about this home since the last inspection. The home has also not received a complaint since the last inspection. Residents spoken with all said that they knew who to complain to if they wanted to make a complaint and that it would be dealt with appropriately. There was no information posted around the home how to make a complaint, however evidence was seen that information was given out when people made enquiries about the home. The Registered Person must ensure that information regarding how to make a complaint is readily available to all residents in a format that meets their needs. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 15 Staff spoken with understood what was abuse and what to if they suspected it however they were less clear what to do if they needed to take the matter further. Currently all staff receive information about abuse awareness during supervision. It is therefore recommended that the Registered Person include information regarding the whistle blowing policy during this time. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Residents live in a clean safe and well-maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the partial tour of the building communal areas were viewed and a selection of residents bedrooms were seen. The home was clean through out and residents spoken with said that their bedrooms were always clean and kept tidy. Evidence was seen that regular maintenance takes place and the home complies with Fire and Environmental Health regulations. This ensures that residents live in a safe and well-maintained environment. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 17 The laundry is suitable to meet the needs of the home with an impermeable floor to ensure that it can be cleaned easily. Infection control within the home is good and staff understand the importance of following appropriate procedures to protect residents from infection. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Staff are employed in sufficient numbers to meet the needs of residents and recruitment practices maintain residents safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas were seen and they evidenced how many staff were on duty. Residents spoken with said that staff were available when they needed them and they came promptly when called. A visitor spoken with commented that, ‘There are enough staff employed, staff are able to spend 1:1 time with my ******’. Evidence was provided to show how many staff had NVQ level 2 training this ensures staff are trained and competent to be carers. Staff employment records were seen and each had an application form and two references. Staff confirmed that they did not start work until a Criminal Records Bureau check was completed. Evidence was seen that POVA First Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 19 applications were being made when Criminal Records Bureau checks were applied for. This ensures that those deemed unsuitable to work with vulnerable people are not employed by the home. As POVA First checks were received as emails it was not always clear which email referred to which member of staff. It is recommended that a system be created to link the two together. There were clear records kept of all staff training showing who had done what training when and when it needed to be renewed. This is good practice. Staff confirmed that they received training and had an induction before starting caring for residents. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. Residents’ benefit from a well run home that is run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been registered as a ‘fit person’ to manage a care home since July 2005 and has experience to manage a care home. As the manager was absent for most of the inspection the inspector was unable to ascertain any further training she may have done since her registration. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 21 The home has a detailed quality assurance system that covers all areas of the service delivered it ensures that residents are able to give their views of the service they receive. Residents’ monies are well managed and stored securely, with all records showing that two signatures are required for all transactions and receipts are kept showing what the money was used for. This minimises the risk of residents being financially abused. Records were seen showing that staff receive mandatory training that is regularly updated. Food is stored appropriately and all temperatures taken for cooked food as well as the fridge and freezer ensuring that residents are not placed at risk through food poisoning. Water temperature is regulated to minimise the risk of scalding and control of the risk of Legionella. All radiators have covers over them preventing residents burning themselves on hot surfaces. Accidents are recorded and the manager ensures that the Commission is notified of all accidents and incidents that affect the residents well being. A requirement was set at the last inspection stating that identified sources of risk must be dealt with swiftly. These areas have now been dealt with and the requirement is met. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement The Registered Person shall unless it is impracticable to carry out such consultation, after consultation with the service user, or a representative of his, prepare a written plan (the service users plan) as to how the service users needs in respect of his health and welfare are to be met. Residents must be where practicable be involved in the creation and review of care plans. The registered person shall supply a written copy of the complaints procedure to every service user and to any person acting on behalf of a service user if that person so requests. Copies of the complaints procedure must be available around the home. Timescale for action 01/03/07 2 OP16 22 (5) 01/03/07 Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 24 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 3 4 5 6 Refer to Standard OP7 OP7 OP8 OP12 OP18 OP29 Good Practice Recommendations The Registered Person should evidence where residents are involved in the creation and review of care plans. Care plans should provide more detail into how carers are to provide the care to the resident. The Registered Person should make alternative arrangements to weigh residents where they are non weight bearing. Record activities that residents take part in. Include information on whistle blowing policy when discussing adult abuse during staff supervision. Create a recording system that links POVA First checks to the member of staff it has been applied for. Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Melbourne Home DS0000006441.V328779.R01.S.doc Version 5.2 Page 26 - 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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