Inspection on 16/10/05 for Min-Y-Don

This inspection was carried out on 16th October 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

Min-Y-Don 07/05/08

Min-Y-Don 21/05/07

Min-Y-Don 15/12/05

Min-Y-Don 21/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Min-Y-Don Min-y-don 24 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP Lead Inspector Mr Ian Harris Key Unannounced Inspection 16th October 2006 08:00 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 Min-Y-Don DS0000064532.V297495.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. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Min-Y-Don Address Min-y-don 24 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP 01902 77 49 50 01902 774 953 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) West Midlands Residential Care Homes Ltd Mr Lee Anthony Bond Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: The home is a large detached, Victorian property set in its own attractive grounds at the end of a private drive. A purpose-built extension has been added to the home. The home, which provides accommodation for 26 service users. The home is within walking distance of Tettenhall village where there is a post office, shops and a variety of other amenities. There are three double bedrooms, and 20 single bedrooms, three bathrooms, one shower, eight WCs, three lounge/dining rooms, a conservatory, laundry, kitchen, staff room and a managers office. There is a large car park and extensive grounds, which include an enclosed garden. The current fees range from £336 to £385 per week. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5 hours in the presence of the Care Manager. During the inspection a tour of the premises took place and staff and care records were inspected. Staff rotas and general records regarding the maintenance of the home were checked and the last reports of the Fire Prevention Officer and Environmental Health Officer were considered. 4 members of staff and 6 residents were spoken to. What the service does well: What has improved since the last inspection? There has been some remedial maintenance work carried out since the home has changed hands and they include the kitchen storerooms and room 7 being redecorated, a new radiator fitted to room 15, a new lift door, and new floor covering in room 22. Outside the building a new side gate has been fitted, the Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 6 window- sills have been replaced by P.V.C. and the garden has been relandscaped. The care manager has introduced formal supervision for staff, a new training programme and a key-worker system of working. 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. The summary of this inspection report can be made available in other formats on request. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 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 Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. 3 and 6 Quality in this outcome area is good. The home has a Statement of Purpose and a Service users Guide. The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. EVIDENCE: All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the home’s assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Six residents files and care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. 7, 8, 9, and 10 Quality in this outcome area is adequate. Each resident has a good, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 10 care Plans are being carried out and reviewed on a monthly basis. However it was noted that some of them lack a detailed risk assessments. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by local practitioners. The records indicate that resident’s medical needs are being met this was confirmed by a number of residents and through observation on the day of inspection. A number of residents stated that the staff arrange for hospital visits and G.P. visit and that they feel that their health has improved since coming into the home. Medication is administered by means of a monitored dosage system. The system appears to be working very well. The home receives good support from the pharmacist. All Senior Staff have been trained to use the system before they are allowed to administer medication and completed the Safe Handling of Medication training course. The home has very good policies and procedures, regarding the administration, storage and recording of medication. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the quiet lounge on the ground floor offers that privacy when not being used. It was observed that residents’ were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. Those residents and spoken to were complimentary regarding the quality of their lives the care they are receiving at the home however a number of residents said that the staff are rushed and they had to wait a long time for staff assistance. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. 12, 13, 14, and 15 Quality in this outcome area is good. The home provides a good programme of social activities within the home, which are designed to meet the capabilities of most of the residents. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. EVIDENCE: The routines and activities within the home are not as flexible as they could be due to the demands of some of the residents and the available of staff. There was evidence to show that staff consult with the residents regarding the choice of meals, activities within the home and outings through the key-workers. The home does not have a staff member designated to organise social and leisure activities and who identified interests the residents wish to pursue, which would be an advantage. It was noted that there is little activities provide for Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 12 residents with Dementia. The home organise entertainment delivered by external entertainers. Comments from residents regarding these activities were very good and it is obvious that some of the residents benefit from them. Records of activities enjoyed by the residents are being appropriately maintained. The residents keep contacts with the local community facilities – for example, some are escorted to, Tettenhall village by their key-worker. An outing on a Narrow Boat trip was arranged in the summer. All residents have been registered with the ring and ride service in order to access transport. Three of the resident stated that they enjoy the outings very much. Staff at the home, encourage regular contact between residents and their relatives by inviting them to parties, fetes, outings and celebrations. It was noted that approximately 5 resident’s are regularly taken out by their relatives. All residents were very complimentary about the standard and choice of food provided. It was apparent that the menu is changed to incorporate seasonal changes. Several service users told the Inspector that the food was good, tasty and well prepared. The kitchen is well equipped, kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. EVIDENCE: The home has a satisfactory comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide, which a is issued on admission to the home. A copy is also placed in the reception hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in internal and N.V.Q. training, which all care Staff undergo. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 14 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): This judgement has been made using available evidence including a visit to this service. 19 and 26 Quality in this outcome area is adequate. The new proprietors have carried out some remedial redecoration and refurbishment, which will maintain the home to an adequate standard. The home would benefit from a rolling programme of redecoration and refurbishment that will bring the home up to a good standard. The provision of a walk in shower would be an improvement for less able residents. EVIDENCE: The home is long established and has undergone alterations over the years in order to provide appropriate accommodation for older people and is maintained to an adequate standard. The home is a listed building and has character however does not have en-suite facilities. The general appearance of the internal environment is dated and a rolling programme of redecoration and Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 15 refurbishment should be introduced to modernise and improve the environment. The replacement of the floor covering in the hall and ground floor corridors and the redecoration of the first floor corridors should be prioritised. The provision of a walk in shower would provide choice and easier bathing for less able residents. The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and the staff have received training in food hygiene and Infection Control. From observations and discussions with staff they appeared to be conscious of the dangers of cross infection. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 16 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): This judgement has been made using available evidence including a visit to this service. 27, 28, 29 and 30 Quality in this outcome area is adequate. The The The The home is staffed with adequate numbers and skill mix of staff. staff have a very good understanding of the residents support needs. home has good policies and procedures regarding the recruitment of staff. manager has introduced a good staff-training programme. EVIDENCE: The inspection of staff rotas and discussions with staff and residents indicated that the home is adequately staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. It was noted that there have been minimal staff changes since the last inspection. However it was noted that as the numbers of residents increase and the dependency levels rise the staff are struggling to provide a good standard of care. Also it is noted that the home is now registered to admit more residents suffering with Dementia. In order to provide a good standard of care the care staff should be increased by 37 hours during the day-time and the night staff should be increased to 3 on each shift. The home operates an acceptable recruitment procedure. On inspecting 6 staff files, there was evidence within them that all C.R.B. checks are being carried out. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training has now exceeded the minimum standard. Care staff have attended courses on Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 17 Safe handling of medication, Dementia care, and Moving and Handling, and Health and safety at work. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 18 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): This judgement has been made using available evidence including a visit to this service. 31, 33, 35, and 38 Quality in this outcome area is good. The home is well managed, where residents interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the records inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety EVIDENCE: The home is well managed by the Care Manager who is qualified in both practice and management and has considerable experience in caring for older people in residential homes There are clear lines of accountability within the Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 19 home and the manager is very supportive of both staff and residents and is well supported by the proprietor. However an appointment of a deputy manager would be an advantage and ensure good support when the manager is off duty. Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. There is a good staff supervision system in place and there is evidence that the staff have regular supervision meetings. It was also noted that the home has a Quality Assurance system in place, which includes questionnaires to residents, visitors and relatives to obtain feedback on the quality of service. Feedback from the last issue of questionnaires was very positive with all feedback stating they are satisfied with the care they are receiving. There was also evidence to show that staff consult with the residents regarding the choice of meals and activities. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Environmental Health Officer which took place on 03/03/06 have been actioned. All safety equipment is regularly checked and well maintained. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 20 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 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 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 Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 21 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 14 Requirement The registered person must ensure that risk assessments are carried out on all residents and a copy is place on file. The registered person must ensure that the levels of care staff are reviewed. The registered person must ensure that the floor covering in the hall and ground floor corridors is replaced The registered person must ensure that the first floor corridors are redecorated. The registered person must ensure that a suitable programme of social activities is provided for residents with Dementia. Timescale for action 01/12/06 2 3 OP27 OP19 18 23 01/12/06 01/01/07 4 5 OP19 OP12 23 16 (2) (m) 01/01/07 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 22 No. 1 2 Refer to Standard OP31 OP19 Good Practice Recommendations The registered person considers the of appointment of a deputy manager. The registered person considers the provision of a walking shower room. Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Min-Y-Don DS0000064532.V297495.R01.S.doc Version 5.2 Page 24 - 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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