CARE HOMES FOR OLDER PEOPLE
Melbourne Home 263 London Road Leicester Leicestershire LE2 3BE Lead Inspector
Keith Charlton Unannounced Inspection 6th December 2005 09:30 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 Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 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.V270333.R01.S.doc Version 5.0 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 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.V270333.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of service. Date of last inspection 7/9/05 Brief Description of the Service: 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 per week, which is generally appreciated by service users. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 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 service user and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included checking the notifications of significant events sent to the Commission for Social Care Inspection by the home. There have been no complaints regarding the service in the last twelve months. The Inspection took place between 9.35 and 13.55 and included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke to nine residents and four members of staff. What the service does well:
Service users again were very positive about their experiences of the care they receive and said staff were very friendly and helpful and encouraged their independence and that the food was very good. They said visitors are made welcome, they liked their bedrooms and they could bring in their own furniture to make bedrooms homely and that they found facilities to be in a clean and tidy condition. Staff were observed to be friendly and respectful towards service users. The cook is proactive in seeking out recipes for service users with different food preferences. Staff were aware of the whistle blowing procedure in case of abuse. A number of staff are now undertaking National Vocational Qualification level 2 training and the Registered Manager has drawn up a training programme to ensure all essential training is covered. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 6 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. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 An assessment procedure is in place so that service users needs can be identified and met. EVIDENCE: An assessment form was viewed which had information regarding a service users health and medical needs. The Registered Manager is to review this so as to include other important issues as per National Standard 3. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Service users are treated with respect and have Care Plans that staff follow. EVIDENCE: The Registered Manager has upgraded the Care Plans from the previous format so that information regarding service users needs is now more wide ranging. Service users said they staff called in medical services when they felt unwell and health conditions were recorded in the Care Plan with input from medical professionals. From speaking to nine service users and observing staff practice it was again evident that service users feel that staff show respect, friendliness and affection towards them, and staff were again highly praised by service users. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 10 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): 13,14 Service users have choice over their lives and visitors are encouraged by the service. EVIDENCE: Service users said that they had a great deal of choice in their lives – when to get up and go to bed, going out, staying in their rooms or coming to the lounge, when they bathe etc. They said staff helped them maintain their independence. A number of visitors were present during the inspection and there was friendly interaction between them and staff. Service users said their visitors were always made welcome. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 11 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 Staff are trained to protect service users from abuse. EVIDENCE: Service user said they were confident that if they had a complaint that it would be properly looked into by the Registered Manager. Complaint forms were available to properly direct this process. Staff were asked as to the adult protection procedure and found to have a good knowledge of this. They said that this is part of the training supplied to them by the Registered Manager. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 12 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): 19,26 Facilities are attractive and well maintained. EVIDENCE: Service users again said that they liked their bedrooms and they were found to be homely and personalised with a range of facilities – telephones, fridges, TVs, pictures, photos, ornaments etc. Facilities inspected were found to be in an odour free, clean and attractive condition and in a good state of decor. . Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 13 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 Staffing levels meet service users needs and there is a recruitment procedure in place to protect the safety of service users. EVIDENCE: A copy of the staff rota was available showing the number and type of staff on duty. Additional staff are rostered during peak times of activity e.g. in the mornings and at meal times. There are a minimum of three care staff on duty for daytime/evening periods and four staff for the morning period. Staff records were found to be in generally good order with Criminal Records Bureau checks taken up. Copies of Protection of Vulnerable Adults checks will be kept in future to prove these were obtained prior to commencement of employment. One record is to be followed up regarding obtaining photo identification. The Registered Manager has drawn up a training audit of essential issues. It was agreed that all current staff will be trained in these within six months. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 14 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): 35,38 Health and Safety systems need to be reviewed to ensure service users are fully protected. EVIDENCE: There are records of service users monies held by the home which detail balances with receipts kept. Two signatures per transaction are to be carried out in future. Some aspects of Health and Safety have been identified - installing window restrictors and the protection of glass in some service users bedrooms – which are currently being attended to according to the Registered Manager. A fire door was found to be held open, due to problems with a service user being accidentally struck by it if anyone came through this door. The
Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 15 Registered Manager stated this was to have an approved fire closure fitted so that it can be kept open. A Risk Assessment was needed so that this practice was not assessed as high risk – the Registered Manager stated this has now been carried out. The hot water temperature was measured and found to be 45.4.c in a bathroom. The Registered Manager stated this had then been lowered to the National Standard 43c. A review of the monitoring arrangement is needed to ensure water is always at a safe limit. Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 16 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 17 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 OP38 Regulation 14 Requirement Identified sources of risk to service users need to be swiftly dealt with. Timescale for action 06/12/05 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 Melbourne Home DS0000006441.V270333.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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