Inspection on 31/01/06 for Minsden

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Minsden 24/07/07

Minsden 29/11/06

Minsden 11/08/05

Minsden 02/03/05

Minsden 08/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Minsden Wratten Road West Hitchin Hertfordshire SG5 2AU Lead Inspector Mrs Alison Butler Unannounced Inspection 31st January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Minsden Address Wratten Road West Hitchin Hertfordshire SG5 2AU 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) 01462 450703 01462 427651 www.quantumcare.co.uk Quantum Care Limited Ms Elizabeth Grace Street Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48), of places Physical disability (1), Physical disability over 65 years of age (48) Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate 1 service user under the age of 65 with a physical disability. Date of last inspection 11th August 2005 Brief Description of the Service: Originally built in 1960, Minsden was first registered with Hertfordshire County Council on 1st July 1992. It was refurbished in the mid- 1990s. The home is situated in a quiet residential area within walking distance of Hitchin town centre. The accommodation is on two floors served by a lift. On the ground floor there are 19 single bedrooms, quiet room, smoking lounge, lounge/dining room, Asian elders day centre, kitchen, laundry room, several offices, 3 bathrooms, 2 shower rooms and toilets. On the first floor are 22 single bedrooms, lounge, kitchen diner, quiet lounge, 3 bathrooms, 2 shower rooms and toilets. To the front of the building there is ample car parking and a medium size garden and patio to the rear. The Asian elders day centre is a particular feature of the home, providing a valuable resource for the local community, open Mondays to Fridays each week. The homes statement of purpose states that the emphasis is at all times on making service users feel that Minsden is their home. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This second routine unannounced inspection was conducted late morning into the early afternoon. The focus of this inspection was on examining the remaining key standards and holding discussions with the manager, residents and staff on duty. Staff were observed carrying out their duties in a caring and relaxed way. Care records were also examined. Where standards remain the same the information has been brought forward from the previous report. This report reflects the findings on the day of the inspection. What the service does well: What has improved since the last inspection? A number of bedrooms have been decorated since the last inspection. This has provided the residents a more pleasant atmosphere in which they can rest if they so choose. Although medication training has been held since the last inspection there were a few issues raised at this inspection. The manager has worked hard to eliminate the odour in the two bedrooms identified at the previous inspection and new flooring has been purchased. Pedal bins with lids have been provided in toilets to better control the spread of infection Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 6 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. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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 Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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): 1 Up to date information is available to prospective residents to ensure they are able to make an informed choice. EVIDENCE: An up dated copy of the Statement of Purpose and Service Users Guide has been received following the appointment of the new manager. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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): 9 A well-managed and safe medication system is in place, although the management must ensure that staff accurately record all medication on the medication administration record (MAR) sheets and in the disposal record. EVIDENCE: Examination of the records of a newly admitted resident showed that some of the medication that had been brought in with them was prescribed for another individual and the home had returned it to the chemist. They had not detailed the medication they had received and returned to the chemist. This does not allow a full audit trail to be conducted. Where changes are made to the MAR sheet the author should sign and date them. Paracetamol, which is given as required, was unable to be reconciled. It recommended that another recording system be considered to allow for ease of reconciliation at any point in time. It is recommended that a thermometer be purchased to monitor the temperature of the medication room to ensure that it remains below 20°C for medication as defined by the manufacturers instructions. All controlled drugs were well kept and recorded accurately. Medication Training has been carried out since the last inspection. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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): Not inspected on this occasion. EVIDENCE: Please refer to the report dated 31st August 2005 for comments. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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 Robust procedures are in place to ensure the protection of the residents. EVIDENCE: A copy of the complaints procedure is available. Residents were aware of whom to speak to if they had any concerns or were unhappy with the care provided. The complaints that had been received since the last inspection had been appropriately recorded with actions, outcomes and responses sent to the complainants. Adult protection is covered in the induction programme and additional training is organised as required. It is recommended that the new staff member is taken through the Hertfordshire County Council procedure as they are not fully clear of this, but they are confident they would report anything that gave them cause for concern regarding care practice. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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, 20, 23 & 26 The home is clean and reasonable well maintained. Regular maintenance checks are carried out on service and equipment. EVIDENCE: There are still areas of the home that are required to be brought up to a acceptable standard. A lot of progress has been made towards redecorating areas of the home since the last inspection. Eight bedrooms have been decorated since the last inspection and carpets are waiting to be fitted. The rooms at the last inspection that had been identified as having lingering odours have been dealt with and the odour eliminated. All areas of the home were cleaned to a high standard. Discussion took place on access to various outside areas and it is recommended that they look at creating a doorway in the quiet lounge and providing further access to the garden as this is a nicely grassed area and would give more choice to residents. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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 & 30. Robust procedures are in place for the protection of the people living in the home. Sufficient numbers and the deployment of staff were adequate to meet the personal care needs of the residents at the time of this inspection. An on going training programme is in place to ensure staff are trained and competent in their roles. EVIDENCE: Staff files examined showed that all the relevant checks had been carried out prior to them beginning employment at the home. Adequate numbers of care staff, domestic and catering staff were available to look after the 48 residents. Observation of staff at work concluded that they were knowledgeable about the needs of the residents and they offered appropriate assistance and encouragement. A full on-going training programme is in place and staff attended as necessary this ensures they are fully competent and up to date with current practice. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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): 31, 33, 35 & 38 The manager has settled in well and was registered with the Commission For Social Care Inspection in September 2005. Health & safety on the whole is well managed and ensures that everyone entering Minsden is protected. EVIDENCE: The manager was registered with the Commission For Social Care Inspection in September 2005; she transferred from a previous home run by Quantum Care. Staff confirmed that the team work well and they very much enjoyed working in the home. Resident’s money is well managed and appropriate records held; there had recently been an external auditor in at the home to ensure they were following the correct procedures. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 15 Regulation 26 reports are carried out although these are not receive by the Commission For Social Care Inspection in a timely manner, the last received was in October 2005. The organisation must ensure that the Commission For Social Care Inspection receive them on a monthly basis. Comprehensive policies and procedures are in place to ensure the health, safety and welfare of all who enter Minsden is promoted and protected. There is a large number of risk assessments in place and these need to be audited and only ones that are relevant be kept this would ease the reading and reviewing of them. They need to ensure that if they are written for an individual they are personalised and not just by adding their name to the template. All accidents and incidents are documented appropriately and a monthly audit is carried out. Appropriate fire checks have been carried out and recorded. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X 3 X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 17 No 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 OP9 Regulation 13(2) Requirement Timescale for action 31/01/06 2 OP33 26 The manager must ensure that all medication entering and leaving the home is recorded in line with the guidance contained within the Administration and Control of Medicines in Care Homes and Children’s Services published by the Royal Pharmaceutical Society published in June 2003 The proprietor must ensure that 28/02/06 reports are received by the Commission For Social Care Inspection every month 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 OP9 Good Practice Recommendations The manager should look at an alternative recording system for given as required medication to enable reconciliation to take place at any point in time. DS0000019470.V280583.R01.S.doc Version 5.1 Page 18 Minsden 2 3 4 OP18 OP20 OP38 All changes made to the MAR sheet should be signed and dated by the author. A thermometer should be purchased to monitor the medication to ensure that it remains below 20°C as per the manufacturers instructions. The manager should ensure that staff are familiar with the Hertfordshire County Council Adult Protection Procedure The company should consider providing additional access to the outside areas through the quiet lounge to provide greater choice for the residents A full audit and review should be carried out on the entire risk assessments folder and ensure they contain only relevant and up to date to ease the reading and reviewing of them for all staff. Minsden DS0000019470.V280583.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Minsden DS0000019470.V280583.R01.S.doc Version 5.1 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. 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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