Inspection on 03/06/05 for Z & M Care

This inspection was carried out on 3rd June 2005.

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

Z & M Care 09/03/07

Z & M Care 24/10/05

Z & M Care 23/11/04

Z & M Care 21/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol 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 1 June 2005 14:00 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 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 H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Z & M Care Address 4 - 10 Lyndhurst Road Hove East Sussex BN3 6FA 01273 323814 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mehdi Moussavi Z & M Care Limited Mrs Zara Fatemeh Moussavi Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (OP) 37. Learning disability (LD) 20 of places Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for thirty-seven (37) older people of whom twenty (20) may be older with a learning disability. 2 The people accommodated will fall within the registered category of old age and learning disability. 3 Residents will be aged sixty (60) or over on admission. Date of last inspection 23 November 2004 Brief Description of the Service: Z&M Care older people’s unit 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.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 H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place at 10am on 1 June 2005, it was facilitated by Mrs Moussavi the Registered Manager and Jess Marsden, Deputy Manager. The inspection took five hours, during which time the inspector was able to speak to many of the residents and observe life in the home. Residents were able to move freely within the home and staff communicated well with both the residents and each other. Residents were all positive about the care they received and their environment. What the service does well: What has improved since the last inspection? On the standards inspected in November 2004, no requirements were made. Since that inspection Mrs Moussavi has completed her Registered Managers Award and NVQ 4. Jess Marsden is halfway through completing NVQ 3 and Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 6 plans to undertake the Registered Managers Award and NVQ 4 in 2006. staff have either completed or are undertaking NVQ 2. All What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 standard(s) 1,2,3,4,5, and 6 is not applicable as the home is not registerd for intermediate care. The statement of purpose and service user guide are updated yearly and on view in the entrance hall of the home. Both provide enough information to ensure prospective residents whether the home will meet their needs. The home undertakes a thorough pre-admission assessment and residents are able to visit prior to admission to ensure suitability on both sides. The home is staffed by trained nurses and care workers: all are familiar with the needs of the residents in the home. EVIDENCE: On admission to the home each resident receives a copy of the statement of purpose and service user guide. Terms and conditions of residency are arranged between the funding authority, the home and the resident. Both the statement of purpose and service user guide are both reviewed in August each year. Pre-admission assessments are undertaken jointly by the Registered Manager and Care Manager to ensure that the residents needs can be met. Pre admission assessments are clear and concise and form the basis for the Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 9 residents care once he/she has been admitted to the home. The Registered Manager told the Inspector that prospective residents are invited to visit the home on more than one occasion to meet staff and other residents. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11. All residents in the home have their personal care needs addressed by the staff. 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 process is overseen by the Deputy Manager and Care Manager. If a resident requires pressure area care, support is sought from the District Nursing Team. The home has a policy for tissue viability that was last reviewed in October 2004. Medication training is undertaken by staff who administer medication and training is provided by Brighton and Hove Council with support from the local pharmacist. Six staff take responsibility for administration of medication, and they monitor the three residents who self medicate, each of which has a locked facility in his/her room to ensure medication is safely locked away. Residents are weighed each month and diets monitored. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 11 The home has a death and dying policy that is reviewed yearly and a privacy and dignity policy that is included in the Residents Charter of Rights. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. The home works hard to allow residents choices in their activities of daily life and to support them in making decisions. Visitors are welcome and communication between staff and relatives is good. Meals are well prepared and the standard good. 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 Care Manager reported that exercises to improve eye-hand co-ordination and dancing are the most favoured. Birthdays are celebrated and residents who are able to are taken to lunch with a relative or friend at a local restaurant or hotel. These trips are organised by the Deputy Manager. The Deputy Manager also takes responsibility for applying for grants to enable residents to have a holiday, he told the Inspector that so far this year holiday destinations are Bournemouth, Isle of Wight and Lourdes. During the inspection residents were able to wander into the office to talk to the Registered Manager and Deputy Manger or Care Manager and it was evident that this is the normal routine. One resident Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 13 played the piano for those sitting in the conservatory and the Registered Manager said that visitors are welcome for lunch as long as a notice is given to the cook. All food is cooked from fresh and the Care Manager told the Inspector that the home actively cuts down on any foods with additives or too much sugar. On the day of inspection the kitchen was very clean and hygienic and the Inspector noted that fridge and freezer temperatures are taken daily and a record kept of the meals prepared. The home has the Clean Food Award. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. EVIDENCE: The home has a complaints policy and a copy is on view in the home. In the main entrance hall a comment box is in place and can be used by residents or visitors to the home. The complaints records showed that the last complaint was made in March 2004, the outcome was recorded and the entry signed. Postal voting is used by those residents who choose to use this system; staff accompany residents to the local polling station if they prefer to vote in person. The Registered Manager told the Inspector that all staff training in the Protection of Vulnerable Adults was completed in April 2005, this included updates. The home has a policy in place that is reviewed regularly and will next be reviewed in August 2005. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21 and 26 The home is in need of repair in places especially the bathrooms that are showing signs of wear and tear. Paintwork in the corridors and around door frames needs freshening up and marks removing where the door has been opened and closed. EVIDENCE: The home was free from offensive smells on the day of inspection, however following a tour of the premises the Inspector and the Registered Manager and Deputy Manager discussed the issues that needed addressing in the bathrooms and toilets where tiles have come away from the wall or are cracked. Floors are uneven and top covers from radiators have fallen off. In one bathroom a shatterproof window is required as it lies directly to the side and above a bath that is used by residents. All points raised are reflected in the requirements of this report. The Registered Manager agreed to address the problems and was willing to arrange repairs immediately. She spoke to both the cleaner and maintenance person with the Inspector to outline concerns and ensure that the Health and Safety aspect of maintaining a safe and clean environment was understood. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 29 and 30 The home has sufficient staff on duty to meet the needs of the residents and takes into account that more staff are required at certain times. The Registered Manager is willing to identify extra training needs staff may have and is very pro-active in encouraging them to further their knowledge. EVIDENCE: The staffing rota for the home showed that between 7am-9am five staff are on duty and between 9am-2pm the home is covered by five staff, the Registered Manager, Deputy Manager two handymen who clean and undertake maintenance, a cook and an escort who arranges general trips for residents and accompanies residents to appointments outside the home. Five care staff work until 9pm and two staff work a waking night with arrangements included in the rota for on-call back-up. The Inspector noted that the home’s training and development policy was updated on 23/4/04. Training is a priority in the home and 100 of staff have either obtained NVQ 2 in care or are attending the course. The Care Manager told the Inspector that she takes responsibility for all induction training and refresher training and this takes place on a weekly basis. The home’s recruitment policy was last reviewed on 26/10/04 and the deputy Manager said he will be reviewing it again in August 2005 to keep it in-line with the home’s other policies. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 and 38. The home is well managed with clear lines of accountability. The outcome for residents’ is good and staff relate well to residents and relatives. There were no concerns about the care received by residents however some areas have been overlooked relating to health and safety in the bathrooms and this has been discussed with the Registered Manager, Deputy Manager, Maintenance person and Cleaner. EVIDENCE: The home has a clear organisational structure that is supported by regular management meetings, staff meetings and resident meetings. A designated resident acts as a spokesperson for the other resident in the home and attends the staff meetings on their behalf. All meetings have an agenda and minutes Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 18 are taken and distributed: staff are invited to put forward items to be discussed. Training is a priority and the Registered manager who has many years experience and has a degree in Social Science as well the Registered Managers award and NVQ 4, attends all training with the staff. She is also a First Aid appointed person. The Registered Manager keeps records of all supervision sessions that take place every two- months, the responsibility for supervision is shared with the Deputy Manager and the Care manager. Responsibility for Health and Safety is taken by the Deputy Manager. Records are kept of all fire drills and the last fire inspection by an independent person took place on 24/8/04. Fire safety refresher training is provided six monthly and fire drills take place every two months where the evacuation process is put in force to the front door. All the fire alarms are tested on a weekly basis. The emergency lighting and the call bells are tested monthly with records kept, all electrical circuits were tested on the 18/11/04 at which time the deputy Manager said some circuits were replaced. The home has an accident book that meets current legislation and the last entry was made on 26/5/05. Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x 1 x x x x 2 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 Standard No 16 17 18 Score 2 2 3 3 3 3 x x 3 x 2 Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 20 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. 2. Standard 19/38 19/38 Regulation 13(4)abc 23(2)abd 13(4)abc 23(2)abd 13(4)abc 23(2)abd 13(4)abc 23(2)abd 13(4)abc 23(2)abd Requirement The toilet on the first floor (medi bathroom) requires cleaning and the floor to be secured. The window in the medi bathroom requires toughened glass and the rusty coat hook to be removed from the wall. Broken tiles in the parker bathroom to be replaced and the old mirror to be removed. The draughty and rotten windowframe in the parker bathroom to be replaced. The bathroom in room 33 to have the top of the radiator cover replaced and the cabinet removed that is old and has sharp edges. The glass window over the bath in room 33 to be replaced with toughened glass. The showerheads throughout the home to be cleaned thoroughly. The overhead light cover in room 33 to be replaced. The trim on the side of the bath in room 33 to be replaced as it is cracked. All bathrooms to be kept hygienically clean throughout the home. Timescale for action 1 July 2005 1 July 2005 3. 4. 5. 19/38 19/38 19/38 1 July 2005 1 July 2005 1 July 2005 6. 7. 8. 9. 10. 19/38 19/26 19 19/38 19/26 13(4)abc 23(2)abd 13(4)abc 23(2)abd 13(4)abc 23(2)abd 23(2)bc 13(4)abc 23(2)abd 1 July 2005 15 June 2005 1 July 2005 1 July 2005 Immediate Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 21 11. 12. 13. 19 19/38 19/38 23(2)bc 23(2)bc 23(2)bc The flush to the toilet in room 24 to be repaired. The side of the bath in room 24 to be repaired and the radiator top to be replaced. The side of the bath in room 26 to be repaired. Immediate 1 nJuly 2005 1 July 2005 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 Good Practice Recommendations Z & M Care H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection 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 H59 H10 S14211 Z M Care V217971 010605 Stage 4.doc Version 1.20 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. 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