Inspection on 21/12/06 for The Mallards Care Home

This inspection was carried out on 21st December 2006.

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

The Mallards Care Home 10/02/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Mallards Care Home 5 Dynevor Road Bedford Bedfordshire MK40 2DB Lead Inspector Leonorah Milton 21 st Unannounced Inspection December 2006 11:20 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 The Mallards Care Home DS0000065406.V308748.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. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mallards Care Home Address 5 Dynevor Road Bedford Bedfordshire MK40 2DB 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) 01234 356988 Lansglade Homes Limited Ms Louise Roper Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (22) The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006. Brief Description of the Service: The Mallards is a registered care home for older people and who may also have physical disabilities and/or dementia. The home is located in a pleasant residential suburb of Bedford with convenient access to the town’s amenities. The building has three stories and has been sympathetically converted to provide comfortable accommodation for twenty-two service users. Bedrooms are located on each floor with easy access to bathroom and toilet facilities. A large lounge and a sepate dining room are located on the ground floor. A further lounge/ diner is situated on the first floor for those who prefer a quieter atmosphere. A large garden is available to service users at the rear of the property. The driveway at the front of the building provides parking for several vehicles. Weekly fees for accommodation at this inspection were £450 -£470. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care (CSCI) since the last visit to and public report on, the home’s service provision in February 2006. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 21st December 2006 between 11.20 and 17.30 were taken into account. The visit to the home included a review of the case files for three service users, conversations with seven service users, a visitor, three members of staff, the manager and proprietor. Much of the time was spent with service users in the ground floor lounge, where the daily lifestyle was observed. A partial tour of the building was carried out and other records were reviewed. There had been much progress in the home since the transfer to the new ownership at the beginning of the year. What the service does well: What has improved since the last inspection? The requirement to replace flooring in a bathroom had been actioned. An ongoing maintenance programme had included redecoration of several areas of the building and replacement of furnishings. The result was an attractive and comfortable environment. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 6 Documents that set out how service users were to be cared for had been improved to provide a clear guide to their individual needs and how these were to be met. Service users’ opinions about their care had been sought and recorded at monthly review meetings. The introduction of the quality monitoring systems had brought about an overall improvement in the administration and management functions of the service. 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. The Mallards Care Home DS0000065406.V308748.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 The Mallards Care Home DS0000065406.V308748.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): Standards 1,2,3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had been provided with sufficient information to make an informed choice about moving into the home. EVIDENCE: The statement of purpose was reviewed at this inspection. It had been updated to take account of the change of ownership. The statement provided a clear guide to the service provision. Copies of this document and the service user guide were available in each of the home’s bedrooms. The service user guide contained a copy the last inspection report and the company’s service contract. A service user and a visitor who acted on behalf of a service user confirmed that they had received a contract and that invoices for fees had been in accordance with contractual arrangements. Care files reviewed showed that satisfactory pre-admission assessments had taken place before service users had been admitted to the home. A service The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 9 user stated that they had visited the home prior to admission and had been shown the bedroom available to them. Another service user said that their family had visited the home on their behalf and a representative from the home had visited them in hospital to explain about the service. The home did not provide an intermediate care service. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had been cared for by a skilled team who were sensitive to their needs and expectations. EVIDENCE: Service users who contributed to the inspection stated that they were satisfied with the arrangements for their care. Comments passed included, “ They can’t do enough for you”, “ I can do what I want”, and “The staff are skilled at assessing your problems and finding ways to help you”. A visitor to the home described the staff as “Attentive to service users and kind”. The care planning documentation seen at this inspection was thorough and provided a detailed guide to needs that took account of physical, health, emotional, social, recreational and religious needs. There was evidence that service users had agreed to these plans and of their contribution to monthly reviews of their progress. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 11 Records indicated that referrals to health care professionals had been arranged. There was evidence of routine treatments for chiropody and optical treatment and contact with service users’ doctors, the continence advisor, district nursing services and various specialist departments at the local hospital. It was reported that arrangements had been made for a domiciliary dental service to visit the home in the near future. Administration of medicines at lunchtime was observed. The practice seen followed safe guidelines, as did the systems for the storage and records for the administration of medicines. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 12 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): Standards 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users had been provided with a lifestyle that met their needs and expectations. EVIDENCE: Service users who contributed to the inspection described their daily lifestyles with satisfaction, “You can do what you want, “Please yourself”, “No rules”, “There are no faults here”. They told the inspector about daily opportunities to participate in board games, or bingo, quizzes and similar. They spoke with pleasure about a summer fete, a trip to the coast earlier in the year and a recent trip to a concert and the Christmas party. The weekly chair exercise activity took place during the inspection, as did a game of bingo. Members of staff were observed to read to service users and to engage them in one to one chats. Visitors were evidently made welcome in the home. One arrived to take a service user out to lunch during the inspection and was observed to be on friendly terms with staff. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 13 Documents seen showed that service users were accorded the right to handle their own financial rights and to access their records. Bedrooms showed that service users had been able to bring personal possessions into the home. Effort had been made to assist service users with the arrangements for their possessions. One service user used a personal computer. The supply of a broadband connection was being discussed with this service user. Service users spoke highly of the meals and the Chef. One service user described the Chef as “marvellous” and another said, “The food is marvellous and the Chef will cook anything you want but he knows what I like”. It was evident from service users’ comments and conversation with the Chef that he took a personal interest in service users’ appetites and food preferences and indeed had frequently provided several alternative dishes to suit healthcare needs and personal preferences. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 14 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): Standards 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements were in place to enable service users to raise concerns and to protect them from abuse. EVIDENCE: Previous inspection of the home had established that satisfactory written complaints and protection procedures were in place. Copies of these were seen in the procedural manual at this inspection. There had been no serious complaints during the last year. Service users confirmed that they were able to raise concerns. “You can say what you think”, “We have a key worker to talk to if worried who would tell the manager”, “I have no complaints at all”. Records indicted that staff had received guidance about protection procedures during induction training and at further in house training. A member of staff was able to describe actions to prevent abuse. Assessment of staff files showed that satisfactory recruitment procedures had been followed to protect service users. Appropriate checks on identity, previous employment history and via the criminal records bureau had been carried out before new personnel had commenced duties in the home. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 15 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): Standards 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had been provided with a clean, safe and comfortable environment that had suitable adaptations to meet their needs. EVIDENCE: Communal areas of the building were assessed during this inspection, as were several bedrooms, toilet and bathroom facilities and the laundry. All of these areas were clean and orderly. Service users’ comments confirmed that they were satisfied with their accommodation and the house keeping services, “My room is kept very clean even ‘though I mess it up”, “It is very clean here”,” My bed is comfortable” and ”Clothes are well laundered”. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 16 Bedrooms seen were well decorated and furnished. Each contained service users’ personal items and memorabilia. Communal areas were similarly well appointed. The dining room on the ground floor was not large enough to accommodate all who lived in the home. There was another lounge/diner on an upper floor. Service users dining in this room confirmed that they preferred taking their meals in this area. Pre-inspection information provided by the proprietor showed that systems were in place to ensure that health and safety systems and equipment were regularly monitored. Routine maintenance checks on equipment had been carried out by qualified persons. Records indicated that training had been provided in relation to safe working practice and a safe environment. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 17 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): Standards 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members of staff were sufficiently skilled and knowledgeable to care for service users’ properly. EVIDENCE: Service users were complimentary about members of staff, “Staff are competent and caring”. “They are always pleasant.” “Staff are friendly”. Members of staff were observed to treat service users with kindness and respect. They showed particular sensitivity towards those service users who had dementia. Rotas submitted for the inspection showed that satisfactory numbers of personnel had been rostered on duty. Service users described the team as busy but raised no concerns about any waiting for assistance. It was explained at the inspection that the senior team had been reorganised. The team now consisted of the manager, two senior carers and a team leader. Staff spoken to confirmed that the senior team had supported them. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 18 The pre-inspection questionnaire provided by the proprietor showed that 50 of the care team had achieved National Vocational Qualifications in Care and that another 3 members of staff were working towards the award. Records of recruitment showed that satisfactory employment checks had been carried out. There were records to show good practice at interview. The services of a professional organisation had been engaged to advise about personnel management and recruitment issues. The overall training record and planned training programme indicated a satisfactory provision. In addition to safety requirements topics covered had included dementia awareness, nutrition and swallowing and diabetes. The proprietors had introduced a thorough induction programme. A recent employee described the induction process and said that it had assisted her to become familiar with her role and the routines of the home. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 19 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): Standards 31,33,35,37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had been managed in the best interests of service users. EVIDENCE: The manager had worked in the home for sometime and had been registered in her post by the CSCI. Her management qualification had predated the introduction of National Vocational Management Awards (NVQ). She was advised that she should seek verification from the awarding body that her qualification was equivalent to an NVQ. The manager spoke highly of the influence and input of the new proprietors. She described the home as “flourishing” under their guidance, an opinion that was confirmed by this inspection. Regular supervision and the introduction of The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 20 professional quality assurance systems had significantly supported the manager to improve the overall performance of the service. Service users described the manager as approachable and commented on the frequent visits of the proprietors and said that they too were accessible. Members of staff were similarly complimentary about the manager and the proprietors. One stated, “It is a lovely place to work in”. Records indicated that service users had been encouraged to voice their opinions about the service at individual monthly reviews, quarterly service user meetings and via the annual quality audit process. The report of the last audit was on file. The manager was advised to include it in the service user guide. The home did not hold monies on behalf of service users. A service user who was included in the case tracking methodology for this inspection confirmed that they managed their personal finances and had been provided with a lockable facility for valuables. Record keeping was of a good standard and in keeping with requirements for the operation of a care home. The procedural manual was a little disorganised so that specific documents was not readily accessible. The manual would benefit from a reorganisation into sections and the introduction of an index. The home’s quality audit systems included regular monitoring of safety systems and equipment. The professional advisory body had provided procedures and proforma documents for safety practice and assessment of risks. Visual checks on equipment at the inspection showed that maintenance checks had been carried out as required. Staff training had included safe manual handling, first aid, health and safety in a care home, fire safety, basic food hygiene, infection control and medication. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 21 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x 3 3 The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP31 OP31 OP33 Good Practice Recommendations The manager should obtain verification from the awarding body that her qualification to manage a care home is equivalent to an NVQ 4 in care management. The procedural manual should be reorganised and include an index so that specific information is more readily accessible. The report of the annual quality audit for the service should be published in the service user guide. The Mallards Care Home DS0000065406.V308748.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 The Mallards Care Home DS0000065406.V308748.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!