Inspection on 20/09/05 for Munhaven

This inspection was carried out on 20th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Munhaven 13/06/06

Munhaven 08/09/04

Munhaven 08/06/04

Munhaven 20/04/04

Munhaven 26/02/04

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 Munhaven Munhaven Munhaven Close Mundesley Norwich Norfolk NR11 8AR Lead Inspector Mrs Geraldine Allen Announced Inspection 20th September 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 Munhaven DS0000035176.V253569.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. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Munhaven Address Munhaven Munhaven Close Mundesley Norwich Norfolk NR11 8AR 01263 720451 01263 722579 trish.aston@norfolk.gov.uk 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) Norfolk County Council-Community Care Mrs Patricia Elizabeth Aston Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 20 Service Users who are Older People. One wheelchair user at point of admission can be accommodated in room number 5. 20th April 2005 Date of last inspection Brief Description of the Service: Munhaven is a care home providing personal care and accommodation for 20 older people. It is owned by Norfolk County Council. The home is located in the seaside village of Mundesley, and is close to all local amenities including shops, pubs, the post office and transport. The home offers ground floor accommodation for up to 20 older people in 19 single bedrooms and 1 shared bedroom used for single occupancy.The home has ample communal space, including 5 lounges and 1 dining room. There are also assisted bathing and toilet facilities within the home. The gardens to the front and rear of the home are easily accessible to service users. There is ample car parking space within the grounds and also on the road. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place during the day of Tuesday 20 September 2005. The inspection commenced at 09:30 and ended at 17:00. Information was gathered in various ways. Before the inspection was due the manager, Mrs Aston, completed a pre-inspection questionnaire and comments were received form other agencies who inspect or visit the home. Comment cards were also received from 4 relatives. During the course of the inspection, most residents were seen and spoken to. Lunch was eaten with 2 residents in the dining room and a further 2 residents were seen and spoken to in some detail. Staff were also seen and spoken to A variety of records were seen, including looking in detail at the care being given to 2 residents and also at 2 staff files. Overall, the standard of care given at this home is very good and residents spoke appreciatively of the care and support given by staff. There were however comments about staff being very busy and not having enough time to talk with residents. Residents also mentioned that some staff work beyond their contracted hours and will also go to the home on their days off to complete paperwork or to help out in other ways. The following parts of this summary were completed with Mrs Aston and her senior team. What the service does well: Staff at the home provides very good care despite the staffing levels and availability of staff. Residents feel well cared for and appreciate all that staff do for them. The home offers good choices to residents. One residents said that it was good to see the choices for lunch on the day of inspection “were to the same standard” as any other day. Another resident said that “sometimes there were too many choices” as all the food was good and tempting. There is an excellent atmosphere in the home that is down to the leadership of Mrs Aston and the efforts of all staff at the home. All residents felt comfortable and amongst friends. Visitors were warmly welcomed. Residents gave many examples of how and why they felt happy and well cared for. Munhaven DS0000035176.V253569.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. Munhaven DS0000035176.V253569.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 Munhaven DS0000035176.V253569.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&6 All residents have their needs assessed before moving into the home. The home only admits residents if their needs can be met. This home does not provide intermediate care. EVIDENCE: Two residents care plans were looked at in detail as part of this inspection. In both cases, full needs assessments had been completed and transfer details were in place, including additional information from the last place of residence, i.e. hospital. Health care information was also included. The pre-admission assessment of needs included health, mobility, personal and social care issues. No residents are admitted to the home for intermediate care. Munhaven DS0000035176.V253569.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, 9 & 10 All residents have a plan of care that sets out what their health, personal and social needs are and how they are to be met. The recording within the daily information sheets needs to be improved. See recommendations. Residents have access to all health care services and staff support them where necessary. The home operates safe medicine procedures and staff are properly trained to administer, record and control medicines. Residents are treated with respect and dignity at all times and they feel their rights are protected by staff. EVIDENCE: Two care plans were looked at in detail. The information contained within them was adequate for staff to know what their individual needs were and how they were to be met. The content of the care plans has improved but there is still the need to include more information, particularly within the daily information sheets. For example, the entries were mainly focusing on tasks, with little mention of social and emotional issues affecting the residents. Also, on one of the care plans, the daily information sheet records a health matter Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 10 for the resident on 13/09/2005, with no further entries relating to this matter up to and including 19/09/2005. There was some suggestion within the care plan that the residents are involved in regular and annual reviews, however they do not sign to confirm their involvement and agreement with any changes to their care plan. Residents described being supported to attend the local GP surgery should they need to consult with a doctor. Staff take residents to the surgery, which is located opposite the home, or residents will attend on their own. The GP will make house calls where necessary. The care plans include correspondence relating to healthcare matters as appropriate. The dispensing of medicines was observed discreetly during lunch. It was seen that the senior member of staff followed the homes procedural guidelines and good practice was seen. Certificates of attendance at care of medicines training were seen on some staff files. Four residents were spoken to in some detail and in private. They gave many examples of how staff respected them and their wishes. They described being treated with dignity and receiving personal care in private. The interaction between staff and residents was observed throughout this inspection and it was seen to be very friendly and warm. Residents and staff appeared relaxed and happy in each others company. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 & 15 There are insufficient staff on duty to enable residents to enjoy a social and recreational lifestyle that meets their expectations and preferences. Residents are able to maintain good contacts with family, friends and the local community. Residents are supported and encouraged to make choices about their daily living. Staff respect these as far as they are able. Residents receive a good, wll-balanced diet that offers choice. EVIDENCE: Residents spoke very highly of the efforts made by all the staff at the home but they referred to the lack of staff time to sit and chat. Staff were equally frustrated and spoke of feeling dissatisfied because there was no time to talk with residents, except when assisting with personal care such as a bath. Staff also said they did not have time during the normal working day to take residents out to the village or the sea front. Staff said they were aware residents wished to talk and enjoyed the opportunity but that it was not unusual to need to make excuses and leave them. In addition to this, it was observed during this inspection that the staff smoking area outside of the building is now being used by residents who do not smoke. One of these Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 12 residents was spoken to and it was clear that this afforded an opportunity to spend time chatting to staff. The home continues to enjoy good contacts with families, friends and the local community. People are frequently dropping into the home and some residents like to sit in the entrance hall so they can see the comings and goings. Staff encourage residents to make choices around their daily living and where possible these choices are respected. Residents described the range of choices, which include where, how and with whom they spend their day. Residents are able to rise and retire when they wish. Residents described feeling in control of their daily living. A meal was eaten with residents as part of the inspection process. The dining room looked attractive, with vases of flowers on the tables. The room was bright and airy despite the décor looking tired and in need of redecoration. The choice menu catered for most tastes and included lamb hotpot, tuna salad or pasta bake. There was an equally good choice of dessert menu. Most plates were cleared and residents confirmed they had enjoyed their lunch “as usual”. One resident was being assisted to eat in the dining room. It was noted that the assistance given was discreet, with the carer sitting beside the resident and holding a conversation throughout. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a complaints procedure that is known to residents and relatives. Any complaints are taken seriously and acted upon. Residents are protected from abuse by staff who have been trained in respect of the protection of vulnerable adults. EVIDENCE: The home’s complaints record book was seen and it was noted that no complaints have been received at the home since the last inspection. The Commission has received no complaints. Those comment cards received from residents and relatives confirmed that the complaints procedure was known. Staff have received training about the protection of vulnerable adults and they were able to demonstrate a good knowledge about this. All staff have been subject to a Criminal Records Bureau/Protection of Vulnerable Adults (CRB/POVA) check and the recruitment processes are robust to ensure suitable staff are appointed. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The environment is maintained to a safe standard, however the re-decoration of some of the communal areas is slow in being tackled. The home was clean and hygienic with no unpleasant odours apparent. EVIDENCE: The environment did not provide the focus for this inspection although it was noted that some improvements to the environment have been made since the last inspection. Areas such as the dining room still need to be re-decorated. Staff are making efforts to ensure the environment is as pleasant as possible, with vases of flowers present in the dining room and other communal parts of the home. During the course of this inspection it was seen that the home was clean and tidy with no unpleasant odours detected. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 15 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, 28, 29 & 30 Staff are not employed in sufficient numbers to meet all the needs of the residents. Residents are cared for by competent and well-supported staff. The home operates good recruitment procedures that protect residents. Staff receive training that ensures they are competent to fulfil their roles. EVIDENCE: The staff rotas for the week of inspection were provided and showed that Mrs Aston continues to work care shifts each week. This usually occurs not less than 2 and often 3 shifts per week. The Commission does not expect a registered manager in a home of this size to be expected to work care hours. This has implications on Mrs Aston’s ability to fulfil her responsibilities as registered manager at this home. The difficulties have been exacerbated by the experienced pert-time administrator being seconded elsewhere. Two administrators, both of whom are inexperienced at this particular home, have filled her hours. Combined with some staff sickness, 23 vacant hours per week and also the recent secondment of one of the care co-ordinators, the home gone through a difficult period in terms of staff cover. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 16 This report includes examples of how the staffing levels have impinged on the ability of staff to effectively meet any other than the physical needs of the residents. Examples of concerns expressed by staff about staffing levels were also given. Based on the staff rotas for the week of inspection, calculations were carried out to assess the level of hours employed at this home. These showed that during the hours when no day care clients are at the home, the allowance equates to 13.9 care hours per resident per week. The home provides up to 4 day care places per day and this can reduce the care hours for each permanent resident to 11.6 care hours per week. For comparison, an other staffing calculation was used. This was the calculation based upon ratios of staff to residents. The findings were as follows: Ratios show that in a home of this size and excluding the manager, 1 senior and 3 care assistants are needed between 08:00 and 22:00 except where day care clients are in the home when the number of care assistants should increase to 4. The staff rota for the week of inspection showed that between the hours of 07:00 and 22:00 the manager or a care co-ordinator and 2 care staff are on duty. Requirements about the staffing levels at this home have been made in the past and have not been met. The levels employed at this time have failed to keep pace with the increasing physical, emotional and social needs of residents. See requirements. This is now subject to separate correspondence with the Local Authority. Throughout this inspection, evidence was obtained that showed the staff at this home work very hard to provide good care and in this they succeed. They are supported by a senior staff group who provide leadership and direction that is based on good practice. The home uses the recruitment procedures developed by the Local Authority. These procedures are robust and are based on best practice. Evidence was seen that staff receive appropriate training in a timely way. There is a commitment to NVQ training for staff. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 17 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): 36 & 38 Staff receive supervision that is recorded. For the most part, the health and safety of residents, staff and visitors to the home is protected. EVIDENCE: Mrs Aston described the supervision process at the home and confirmed this was shared by the care co-ordinators. All formal supervision is recorded but informal supervision is not. Staff attend regular staff meetings and these are fully minuted. A staff handover meeting is held at the start of each shift. Health and safety matters were reviewed and it was noted that a good fire pack has been developed. The pack includes fire procedures, plans, training and risk assessments. The fire log showed that the fire alarms are not being tested on a weekly basis. See requirements. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 18 Accident records were seen. The home is using the NCC format which is produced on large sheets of paper. This is causing some storage difficulties that Mrs Aston is addressing. The audit of accident records is not taking place due to time constraints. This is an important management function to ensure that areas of risk are identified and dealt with in a timely way. Chemicals were seen stored in the staff toilet. This area is accessible to residents and consideration needs to be given to the level of risk and how these chemicals are stored. It is recommended that a risk assessment is done and consider what is appropriate action to reduce risks. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 19 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 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 2 13 3 14 3 15 3 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 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X 2 Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 20 YES 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 OP27 Regulation 18 (1)(a) Requirement The Registered Person must ensure that staff are employed ion sufficient numbers to ensure that all needs, including social needs, are met. THIS REQUIREMENT IS REPEATED. The Registered Person must ensure that fire alarms are tested weekly and recorded accordingly. Timescale for action 18/10/05 2 OP38 23 (4) 27/09/05 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 2 3 Refer to Standard OP7 OP7 OP38 Good Practice Recommendations It is recommended that residents are encouraged to sign the care plans to show their involvement and agreement with the plan. It is recommended that the daily information sheets are used to record all social and emotional issues. It is recommended that an audit of accidents is undertaken on a regular basis to ensure patterns are DS0000035176.V253569.R01.S.doc Version 5.0 Page 21 Munhaven 4 OP38 identified and measures taken to reduce risks in a timely way. It is recommended that the storage of chemicals in the staff toilet is reviewed to ensure risks to residents are minimised. Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Munhaven DS0000035176.V253569.R01.S.doc Version 5.0 Page 23 - 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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