Care Home: Musmajas

What the care home does well In regards to this incident there is no areas where this service has performed well. What the care home could do better: The manager must ensure that there are suitable care plans in place that are up ro date and give clear direction to staff on the needs of the person. Risk assessments must be re-visited on a monthly basis or more often if the health or behaviour of a person changes and care plans should be developed to inform staff of actions to take to assist the individual or minimise the risk. Training in First Aid and Health and Safety must be undetaken to ensure that staff understand the actions to be taken to ensure that each person receives treatmentthat is appropriate and ina timely manner. The manager must ensure that records are kept safetly and are available to be viewed by the person concerned, their relatives or other bodies who have access to these. Risk assessments in relation to the environment must be undertaken for each person where there is individual risks and actions put in to place to minimise these. Each person must have access to other professional who can assess their needs and put in to place actions to take to minimise risk and ensure a good outcome. Inspecting for better lives Random inspection report Care homes for older people Name: Address: Musmajas Priory Hall Wolston Nr Coventry West Midlands CV8 3FZ one star adequate service 06/10/2008 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Suzette Farrelly Date: 2 7 0 2 2 0 0 9 Information about the care home Name of care home: Address: Musmajas Priory Hall Wolston Nr Coventry West Midlands CV8 3FZ 02476542701 02476542737 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Latvian Welfare Fund, care home 18 Number of places (if applicable): Under 65 Over 65 18 old age, not falling within any other category Conditions of registration: Date of last inspection Brief description of the care home 0 0 6 1 0 2 0 0 8 Musmajas is a care home set in its own grounds approximately 1 mile from the village of Wolston. The property is owned by the Latvian Welfare Society and was developed into a care home to serve the Latvian community in the Midlands. The home can accommodate up to 18 service users in single room accommodation. Accommodation is sited in the large manor house and surrounding bungalows. Musmajas provides personal care to frail elderly people most of whom originate from Latvia. The homes staff consists of English and Latvian speaking carers who can also converse in English. No intermediate or specialist care is offered at this home. Medical services are provided by the local GP practice. Care Homes for Older People Page 2 of 9 What we found: A random unannounced inspection was carried out in response to a safeguarding issue that was received by Warwickshire Social Services [who lead in all safeguarding [abuse] issues]. The concern was related to a person who was admitted for respite care [this is a short term place to either assist families or give the person a rest from home]. The incident involved the person falling out of bed and burning their face on a hot water pipe. This inspection was undertaken to examine the persons records and establish if appropriate risk assessments had been completed and to confirm the immediate action taken by the staff when the incident occurred. We looked at this persons records, pre-admission information, and plans of care, risk assessments in place, daily records and any accident/ incident forms. There were care plans in place; these did not have accurate up to date information. The manager told us that this persons health had deteriorated since admission and had required assistance with mobility and was more restless. The care plans did not reflect this. Daily records were available up to 9th November 2008, the remaining records [approximately 20 days] were missing, which meant that we were unable to establish what care was given and the health status of this person. There were risk assessments for mobility dated 27th October 2008, which stated that the person was mobile using a stick and required a wheelchair when going outside. The risk assessment and care plan had not been up dated when the mobility changed and required two people to assist. There was a body map, which showed that this person had a sore to their ankle and toe and had reddening skin to their sacrum. The district nurse had seen these; there was no care plan to advise staff on how to manage these sore areas and what to do to prevent further deterioration. The manager told us that this person had fallen out of bed two days after admission, there was no record of this in the daily records, no accident form and the care plan had not been changed to reflect this. The manager told us that after this event the relative arranged for this persons double bed to be delivered to the home, believing this might prevent further falls. There is no evidence that an occupational therapy visit was considered to assess this persons needs. There is a statement from the carer who worked the night that this person fell and burned their face. They state that at 5:00 am this person was in bed, when checked again at 6:05 am they found them trapped between the bed and the wall. Once the carer had called for assistance and this person was helped back into bed the burn was noted to the face. The carer wrote that the person did not seem distressed and had not called out. It was established that they could not reach the bell and that the carer was not in the area so would not have been able to hear this person if they did call. The manager admitted that she had advised the staff to apply Vaseline, which is the wrong advice for a burn. Also that she decided to wait for the district nurse to visit, as Care Homes for Older People Page 3 of 9 the person did not seem distressed. This meant that immediate treatment was not given as required. We toured the home and checked that the call bells for the main house and bungalows could be heard in all places around the service. It was found that the call bells can be heard in all areas of the service and that there are call points where the carer can see which room the call is coming from. We check staff training records to establish that they have sufficient training to carry out their jobs. We specifically looked at First Aid and Health and Safety training. It was noted from the training records and confirmed by the manager that there had been no First Aid training since 2006 and 9 out of 13 carers had completed this. Health and Safety training had not been up dated since 2005. This does not assure that staff are able to deal with basic first aid and this may put people at risk when initial accidents occur. The manager sent us a Regulation 37 Notification [this is required by law to inform us of anything that affects the well being of people using the service]. She had stated on this that the person had fallen sustaining a graze to their face, instead of a burn. The manager informed the Health and Safety Executive after we requested that they did this. Health and Safety have visited and left a report, the manager was unable to find this at the time and told us that she would fax this to us. We have received this and the report states that the management must ensure that there is a suitable health and safety policy in place and that risk assessments are carried out, there was no evidence that this has been addressed. It was seen that some of the exposed hot water pipes have now been boxed in which will prevent any further incidents of this nature. There remain rooms with exposed pipes and it was noted that the persons bed is in a position that a similar incident could occur. The manager had not completed individual risk assessments to determine the level of risk to each person. What the care home does well: What they could do better: The manager must ensure that there are suitable care plans in place that are up ro date and give clear direction to staff on the needs of the person. Risk assessments must be re-visited on a monthly basis or more often if the health or behaviour of a person changes and care plans should be developed to inform staff of actions to take to assist the individual or minimise the risk. Training in First Aid and Health and Safety must be undetaken to ensure that staff understand the actions to be taken to ensure that each person receives treatmentthat is appropriate and ina timely manner. The manager must ensure that records are kept safetly and are available to be viewed by the person concerned, their relatives or other bodies who have access to these. Care Homes for Older People Page 4 of 9 Risk assessments in relation to the environment must be undertaken for each person where there is individual risks and actions put in to place to minimise these. Each person must have access to other professional who can assess their needs and put in to place actions to take to minimise risk and ensure a good outcome. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 Appropriate arrangements for the recording, storage and safe and administration of medications must be made. The concerns identified in this report regarding the storage of medication to be returned, storage of medication requiring refrigeration, signing of medication administration records, and recording details of medication refused must be addressed within a risk management framework. This is to ensure that residents are protected from harm from unsafe medication practices 21/11/2008 Care Homes for Older People Page 6 of 9 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Each person must receive treatment, advice and other services from any health professional as needed. This will ensure that actions taken by the home are approprite, safe and meet the persons needs. 15/03/2009 2 7 17 All record of each person must be kept in a secure place. This will ensure that records related to each person are available for use and to examin if required. 15/03/2009 3 7 15 Care plans must be available 31/03/2009 for all assessed needs. This will ensure that staff are aware of the actions they should take to meet each persons needs. 4 7 12 Care plans must be up to date and state clearly the care required. This will ensure that there is 31/03/2009 Care Homes for Older People Page 7 of 9 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action consistent and appropriate care. 5 8 13 Risk assessment in regards to hazards in the environment must be undertaken and actions put into place to minimise these This will ensure that each person is safe and any risks to their well being is minimised. 6 8 13 Risk assessments must be completed and re-assessed when health issues change This will ensure that the care given is safe and appropriate. 7 29 18 All staff must have up to date training in First Aid This will ensure that immediate actions taken when accidents accur are appropriate and safe. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 15/03/2009 31/03/2009 31/03/2009 Care Homes for Older People Page 8 of 9 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. 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