Inspection on 07/09/05 for Melbourne Home

This inspection was carried out on 7th September 2005.

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 01/02/07

Melbourne Home 06/12/05

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 Keith Charlton Unannounced 7 September 2005 at 9.30am 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 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 DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Melbourne Home Address 263 London Road Leicester Leicestershire LE2 3BE 0116 2706771 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Melbourne Hall Home Trust Deborah Edwards Care Home 17 Category(ies) of OP Older People - 17 registration, with number of places Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 11/1/2005 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 DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 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 two 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 Home’s Registered Manager was not on duty. Care staff ably assisted the inspector. Planning for the Inspection included reading the Pre-Inspection Questionnaire completed by the Manager and Comment Cards returned by relatives, GPs and service users. The notifications of significant events sent to the Commission for Social Care Inspection by the home were also reviewed. There have been no complaints regarding the service in the last twelve months. The Inspection took place between 9.35 and 13.40 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke to eight residents and five members of staff. The inspection was completed with the Registered Manager on 12/9/05. What the service does well: Service users said that the food was good, staff were friendly, activities were organised and appreciated, including the recent outing enjoyed by service users who went, visitors are made welcome, that they liked their bedrooms and they could bring in their own furniture to make bedrooms homely. Facilities were found to be in a generally clean and tidy condition. Staff were observed to be friendly and respectful towards service users. The cook has been proactive in seeking out recipes for a service user with different food preferences. Relatives and GP remarks in Comment Cards praised the care that is given by the staff. Staff are asked to read service users Care Plans and the Policies and Procedures of the home so that they know what to do and are consistent in their work. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 6 Service users are encouraged to retain their independence and service users are supplied with equipment to assist them with eating – special plates etc. There is always a choice of food for each meal. 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. 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 Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 7 contacting your local CSCI office. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4 Some staff are not fully aware of service users conditions. EVIDENCE: Service users have a range of disabilities. Staff have received training or there is information regarding conditions, which the Registered Manager intends to ensure that staff read or receive training. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7.9,10 Service users are treated with respect and have Care Plans that staff follow. EVIDENCE: The Registered Manager is in the process of upgrading the Care Plans from the previous format. Staff said that they had read Care Plans. Medication records were found to be up to date. Service users can manage their own medication if possible. Only staff that have received training can issue medication. From speaking to eight service users and receiving a total of fourteen Comment Cards from service users it was very evident that service user feel that staff show proper respect and friendliness towards them, which was also observed by the Inspector. Frequently staff were highly praised by service users. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 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 standard(s) 12,15 Activities generally meet service user needs. The food is well prepared and tasty and was generally praised by service users. EVIDENCE: The Home has a small programme of in-house activities, and events both internally and externally are organised by the Home. There was one comment in a Comment Card that activities were not sufficient. However service users are asked during their meetings what activities they would like and this will be repeated to ask for ideas. Service users asked said they were satisfied by this choice and some said that it was good they could choose to opt out of taking part in activities. Service users said that they liked the food. The dinner served was home made and was very tasty. The cook asked a service user what she wanted for dinner. There is an alternative to the main meal if wanted by service users. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 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 standard(s) 18 Service users are protected from abuse. EVIDENCE: Staff were asked as to the adult protection procedure and found to have a good knowledge of this. The Registered Manager has produced a policy and procedure relating to how to deal with challenging behaviour of service users if needed. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 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 standard(s) 19 Facilities are generally attractive and well maintained. EVIDENCE: Service users said that they liked their bedrooms and they were found to be homely and personalised with a range of equipment – telephones, fridges, TVs etc. Service users can have kettles and prepare their own breakfasts if able to do so. Facilities are kept in a generally clean and attractive condition. One carpet needed attention, as it was odouress. This is to be intensively cleaned. Service users also positively commented upon the attractively kept gardens. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staffing levels meet service users needs. 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. There is one waking night staff and one sleep in staff. Staff are employed specifically as care, cook or domestic staff. The home employs auxiliary staff - cooks, kitchen assistants, a gardener etc. This was found to meet the requirements of the Commission for Social Care Inspection. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,38 The Health and Safety of service users is not fully protected. EVIDENCE: The Home seeks the views of service users and has extended this process to other stakeholders (GP’s, District Nurses, relatives etc) to ensure there is a Quality Assurance system in place. Staff within the Home have received supervision though this has been irregular. The Registered Manager stated that this is now in hand again. Monthly Regulation 26 Monthly Reports from the Registered Provider on the running of the service are sent to the Commission for Social Care Inspection. Risk assessments in safe working practices have been completed. Some aspects of Health and Safety were identified but not dealt with as a result – installing window restrictors and the protection of glass in some service users bedrooms. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 16 A fire door on the first floor was propped open. It was then shut to ensure fire safety. Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 3 x x 3 x 2 Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 18 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. Standard 38 Regulation 14 Requirement Identified sources of risk to service users need to be dealt with. Timescale for action 12/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 19 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Melbourne Home DC51 C01 S6441 Melbourne Home V247904 070905.doc Version 1.40 Page 20 - 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. 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