Inspection on 24/10/05 for Z & M Care

This inspection was carried out on 24th 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

Z & M Care 09/03/07

Z & M Care 01/06/05

Z & M Care 23/11/04

Z & M Care 24/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE Z & M Care 4 - 10 Lyndhurst Road Hove East Sussex BN3 6FA Lead Inspector Linda Khot Unannounced Inspection 26th October 2005 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 Z & M Care DS0000014211.V250555.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. Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Z & M Care Address 4 - 10 Lyndhurst Road Hove East Sussex BN3 6FA 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) 01273 323814 Z & M Care Limited Mrs Zara Fatemeh Moussavi Care Home 37 Category(ies) of Learning disability (20), Old age, not falling registration, with number within any other category (37) of places Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtyseven (37). Service users accommodated will be older people of which twenty (20) may have a learning disability. Service users will be aged sixty (60) years and over on admission. Date of last inspection 1st June 2005 Brief Description of the Service: Z&M Care older people’s home is registered for 37 residents, 20 of which have a learning disability. Z&M Care also have an adjacent and integral group home, which is registered for 7 adults (18-65) years with a learning disability. The home is part of an Edwardian terrace that has been extended to meet the needs of the residents users. The Registered Manager has applied for planning permission to extend the home again to provide extra bedrooms, a staff room and an extension to the lift shaft enabling it to reach the top floor of the home, initially the application has been denied, however an appeal is taking place. The home is situated in a quiet residential road near to the busy Seven Dials area that has facilities for shopping, including a bank and post office, cafes and a restaurant. There is a corner shop nearby. The home is close to both Brighton and Hove mainline stations. Parking is available in the roads near to the home and is either resident parking only or via a meter system for up to 4 hours at any one time (total cost £2) at the time of this inspection. Public transport is available locally to all parts of the city. The area is well serviced for parks, churches, pubs and leisure activities including the Sussex County Cricket Ground.The home has the Investors in people Award and the Clean Food Award.The main ethos of the home is to promote independence and both the Registered Manager and staff are pro-active in giving service users encouragement and support in achieving this goal. Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a two-day period, initially in conjunction with the home for young adults. The Inspector was able to speak to a large number of residents, either in a group or individually, and seven staff. Many of the environmental requirements requested during the inspection in June had been addressed or had been planned and were awaiting the services of a builder. On the day of inspection residents appeared comfortable and content and were keen to speak with the Inspector about their life in the home. There were no apparent offensive odours and the home was clean and tidy. The Registered Provider/Manager and the Deputy Manager facilitated the inspection on both days. Feedback was given during and after the inspection and all requirements made in this report discussed. What the service does well: What has improved since the last inspection? Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 6 At the last inspection the Inspector made requirements relating to the environment, the majority had been addressed with a few outstanding where builder’s estimates or work had been requested. The sun lounge furniture has been replaced and the main sitting room that residents share has new chairs that are attractive and serviceable. 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. Z & M Care DS0000014211.V250555.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 Z & M Care DS0000014211.V250555.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): All standards were assessed in June 2005 and were not been inspected during The inspection of 24 and 27 October 2005. EVIDENCE: Z & M Care DS0000014211.V250555.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 and 10. All residents in the home have their personal care needs addressed by the staff and careful attention is paid to care planning. On the day of inspection all residents appeared to be well cared for and comfortable in the home, those spoken with stated they were happy in their surroundings. EVIDENCE: Each resident has a care plan and risk assessment that is reviewed monthly. A senior member of staff takes responsibility for this; the Deputy Manager and Care Manager oversee the process with responsibility taken by a senior carer. Trained staff give medication, and risk assessments are in place for the two residents who choose to self medicate. It was agreed that a member of the care staff who will be taking more responsibility would receive a refresher course in the administration of medication. During the Inspection the Registered Provider/Manager raised concerns about a resident who’s changing needs were causing concerns about her safety. Through discussion it was agreed that following a meeting with the residents funding authority and relatives, steps would be put in place to resolve the situation. Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 10 The Inspector was able to speak to a number of residents who confirmed they are treated with respect and dignity. One reported that he had ‘complete privacy’ and another that she feels her room is ‘peaceful and private’. The Inspector noted that staff do speak to residents politely and knock on doors before entering individual rooms. The home has a policy in place for administration of medication that is supported by training for staff, and a privacy and dignity policy. The Inspector saw the induction training records showing that these topics are covered early in the employment of new staff. Z & M Care DS0000014211.V250555.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 and 14. The Registered Manager/Provider is pro-active in ensuring that residents live in the home in a way they themselves are comfortable with. Activities that individual residents enjoy are encouraged and they are helped to exercise choice and control over their lives. The staff are able to accommodate residents from different social and cultural backgrounds taking into consideration their different needs. EVIDENCE: Through discussion with both senior staff and residents it was clear that activities take place each afternoon in the home and residents are able to make a choice as to whether they join in or not. The Inspector spoke with some residents who enjoy providing their own activities i.e. knitting and jigsaw puzzles, watching their own televisions, reading or writing. One resident likes to assist in the garden and enjoys spending time outside in pleasant weather. Although standard 15 was not inspected this time, all residents said they enjoyed the food and that portions are sufficient. Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,and 18. Residents are protected by the home’s attitude to complaints and staff are aware of their responsibilities in ensuring that residents are protected from abuse however one member of staff requires updates on the protection of vulnerable adults procedures to support her existing knowledge. EVIDENCE: The home has a complaints policy in place and since the last inspection the home has received one complaint that was resolved and the Commission for social care Inspection made aware of the outcome. Records of the complaint had been kept on the residents file and the Inspector suggested they be entered in the complaints recording book for future reference. It was noted during the inspection that two residents spoke to the Registered Provider/manager about things that were worrying them and the matters were both dealt with empathetically and resolved immediately. Staff spoken with by the Inspector were aware of the procedure for the Protection of Vulnerable Adults, however it was agreed that a newly appointed senior carer requires updating to support her existing knowledge. The registered provider, Deputy Manager and Care Manager have all received management training in POVA. It was also agreed that staff be given some in-house refresher training and a copy of the flow-chart that is displayed in the office to support good practice. The Deputy Manager told the Inspector that the home had just completed and returned the forms for those residents who wish to use the postal voting Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 13 service. station. Others who choose to will be accompanied to the nearest polling Z & M Care DS0000014211.V250555.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): 19,20,22,23,24 and 25. The home ensures that residents have comfortable bedrooms that suit individual needs and encourage residents to bring their own possessions with them to enable them to feel more at home. Some areas of the home still need to be improved cosmetically and in some places small repairs are required to ensure the safety or comfort of the residents. EVIDENCE: Requirements were made in the last report relating to the environment and the Inspector noted that these had been addressed. In relation to one bathroom the Deputy Manager explained that the colour scheme is being changed therefore the bath panel would be repaired when the builder commenced work on 23/11/2005. The plans for the new laundry had been agreed and estimates requested. The home was clean and tidy and the Inspector was able to tour the premises and speak to some residents about their rooms. All said they liked their rooms and one resident remarked that the home allowed residents to live as they did at home. Residents supported the fact that their rooms are vacuumed regularly Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 15 and their sinks and toilets cleaned. The home has three sitting rooms for residents to use, this includes a smoking lounge. The main sitting room has new seating that is colourful and practical and the sun lounge where residents often entertain their visitors has a new three-piece suite. The Deputy Manager told the Inspector that due to constant wear the carpets in the home are cleaned daily and shampooed at least monthly. The home has bathing facilities and aids and equipment to suit the needs of the residents, all lighting is domestic in character apart from the kitchen that has fluorescent lighting. The home does have a lift servicing two floors however plans to extend it to the top floor have been refused by Brighton and Hove Council. The Registered Provider/Manager told the Inspector that she is concerned that as the residents are ageing they will not always be able to use the stairs and therefore she is going to appeal against the Council’s decision. In some of the toilets, toilet roll holders had been removed and it was agreed that these would be renewed with a different design. Net curtains in some areas need to be replaced where they are either worn or damaged and the Care Manager agreed to address this. In bathrooms where there is frosted glass the Inspector suggested that some form of curtaining or blinds also be provided to promote privacy when the light is on during the dark evenings. Window restrictors to some rooms on the second floor were not in place and the Deputy Manager agreed to look at this by risk assessing the residents for their safety. The Inspector noticed that some residents had freestanding radiators to boost the temperature in their individual rooms and the Deputy Manager agreed that he would risk assess the residents to use them, especially as winter is now approaching and the temperature dropping. A discussion took place concerning the ceiling in Room 15 b and the home needs to ensure it is repaired. Where one resident’s needs are changing discussion took place about the provision of more suitable floor covering being provided, with the agreement of the resident and his relatives. The toilet door on the first floor requires the replacement of the lock fitting so staff from the outside can access it. The shower unit in the shower room outside Room 36 requires repair to the tiles and a shelf for toiletries. Requirements will be made in this report relating to the findings and have been discussed with the Registered Provider/Manager and the Deputy Manager. Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30. The home ensures that there are always sufficient staff on duty that are trained and experienced to care for the residents. EVIDENCE: During the Inspection the Inspector discussed staff roles and staffing numbers independently with both management and care staff. This revealed that staffing at weekends needed to be re-designed to ensure that work was allocated efficiently enabling the five members of staff to share the workload. On the second day of inspection, this had been achieved with appropriate arrangements in place that were clear and acceptable to all staff. The registered Provider/Manager and Deputy Manager share the on-call rota throughout seven days a week. Z & M Care DS0000014211.V250555.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): 31,34,36 and 38. The management structure in the home is defined clearly and residents are safeguarded by the home’s attitude towards the management of their finances. The management of using volunteers in the home from local organisations needs to be reviewed. EVIDENCE: Conversations with care staff revealed that they felt supported by the management staff that set examples of clear lines of accountability and responsibility within the home. Residents manage their own finances and have their own bank accounts. All funding authorities with the exception of one act as the ‘corporate appointee’ for residents they fund, however the Registered Provider/Manager told the Inspector that she still acts for one resident who has no other advocate. Records and receipts were seen of financial transactions concerning personal allowances. Up to date records are kept of any cash kept on site by the home Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 18 and bankbooks are kept by the home if a resident request it. The Deputy Manager, who takes responsibility for keeping the records told the Inspector that the home is not privy to residents ‘pin’ numbers. Through conversation it was noted that volunteers visit the home to assist with general gardening duties and chatting to residents. This is arranged by a local agency. The Registered Provider/Manager said they are always accompanied and the situation has been short term. It was agreed that the home would review its volunteer policy and check with the organisation if a CRB check is required. During the inspection the Registered Provider/Manager discussed security arrangements for one resident with changing needs. The Inspector referred this for advice and on day two of the inspection it was agreed that the use of a discreet tagging system be used to ensure that the resident did not walk out of the home unobserved. Staff training takes place in moving and handling, health and safety, food hygiene, control of infection and first aid. One member of staff who is taking more responsibility in the home needs to undertake refresher training in these subjects to support her existing knowledge. Records are kept of all servicing and testing of gas and electrical installations. In addition to this the water is sent away for safe water analysis, water temperatures are checked and the emergency lighting system checked regularly. At the time of inspection, the report from the latest fire inspection in October was due. Z & M Care DS0000014211.V250555.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 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 3 3 3 3 2 x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x 3 x 2 x 2 Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 20 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 2 3 4 Standard OP9 OP18 OP19 OP19 Regulation 13(2) 13(6)(7) 23(2)c 23(2) 12(4) Timescale for action The newly appointed senior carer 15/12/05 undertakes medication training to update her knowledge. The newly appointed senior carer 15/12/05 undertakes POVA training to update her knowledge. Toilet roll holders to be replaced 15/12/05 or renewed to suit the needs of the residents. Net curtains to be repaired or 15/12/05 replaced where they are torn or ill fitting. Bathroom windows with frosted glass to have curtaining for privacy when the light is on. The ceiling in Room 15b to be 15/12/05 checked and repaired. Flooring in the bedroom on the 15/12/05 top floor to be replaced to meet the needs of the resident. The lock to the door of the toilet 15/12/05 on the first floor to be replaced to make it accessible to staff in the case of an emergency. The freestanding radiators used 15/11/05 in the home for back-up heating in residents rooms to be risk assessed for residents’ safety. The volunteers’ policy to be 15/12/05 DS0000014211.V250555.R01.S.doc Version 5.0 Page 21 Requirement 5 6 7 OP19 OP19 OP19 23(2)b 13(3)(4) 13(4)b 23(2)c 13(4) 8 OP25 9 OP36 19(5)a-d Z & M Care 10 OP38 13(3)(4) (5) 18(1)ac reviewed and the home to investigate CRB checks for volunteers visiting the home to undertake specific duties. The new senior carer to have 15/01/05 updated training in moving and handling, health and safety, control of infection and first aid. 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 OP18 Good Practice Recommendations All staff to receive a copy of the POVA flowchart to support their knowledge. Z & M Care DS0000014211.V250555.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Z & M Care DS0000014211.V250555.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. 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!