Inspection on 17/10/07 for 12 Marine Approach

This inspection was carried out on 17th October 2007.

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

12 Marine Approach 08/11/06

12 Marine Approach 14/02/06

12 Marine Approach 06/12/05

12 Marine Approach 31/01/05

12 Marine Approach 31/01/05

12 Marine Approach 31/01/05

12 Marine Approach 31/01/05

12 Marine Approach 14/04/04

12 Marine Approach 14/04/04

12 Marine Approach 14/04/04

12 Marine Approach 14/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE 12 Marine Approach 12 Marine Approach Canvey Island Essex SS8 0AL Lead Inspector Diana Green Unannounced Inspection 17th October 2007 10:30 X10029.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 12 Marine Approach DS0000029503.V354981.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 and Care Homes for Adults 18 – 65*. 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. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Marine Approach Address 12 Marine Approach Canvey Island Essex SS8 0AL 01268 690495 01268 690495 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) Dargaz Limited Mrs Marie Louise Jeanne Martinson Care Home 5 Category(ies) of Learning disability over 65 years of age (5) registration, with number of places 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2006 Brief Description of the Service: 12 Marine Approach provides care and accommodation for up to five adults with a learning disability, some of who may be over 65 years of age. The home is a large family style chalet bungalow in keeping with houses in the locality. The accommodation is spacious with a variety of communal spaces for sitting, eating and activities. All bedrooms are single and situated on the ground and first floor. The first floor is accessed via a staircase; there is no passenger lift. There is a bathroom and separate WC on the ground floor and a shower room and separate WC on the first floor. There is a pleasant garden/patio area to the front and rear of the property. Limited parking is available to the front of the home. The fees range from £500.00 £570.00 weekly. Additional costs apply for chiropody, toiletries, sundries, hairdressing and newspapers. This information was provided to the CSCI on 16/11/07. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 17/10/07, lasting 4 hours. The inspection process included: discussions with two senior care staff and three residents; a full tour of the premises including residents’ rooms, bathrooms, communal areas, the kitchen and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Surveys were distributed to residents, relatives, care managers and health care professionals and the views from those completed and returned to CSCI have been included in the report. Information from the home’s Annual Quality Assurance Assessment has also been included in this report. Twenty-three standards were inspected and five requirements and four recommendations made. All staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Person centred planning has been further developed. Staff training on infection control and fire safety, basic first aid and moving and handling has been provided. An audit has been undertaken of the home’s infection control standards using the Department of Health’s ‘Essential Steps’ Audit tool. A new conservatory has been built and furnished. Windows have been replaced and new washing machines and television purchased and an ariel erected in preparation for digital viewing. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 6 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. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 3, 6 Residents were well informed and had their needs assessed prior to moving in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been no admissions since the previous key inspection, however senior care staff were able to demonstrate that a full multi-disciplinary assessment of care needs would be undertaken for potential residents prior to admission to ensure their needs could be met. The assessments viewed confirmed that the resident, relative and social worker had been involved in 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 9 the process. Residents’ likes and dislikes were detailed together with appropriate risk assessments (falls, moving and handling, personal risk etc.) Feedback received from relatives confirmed they had been fully involved in the assessment and had been encouraged to visit the home and spend time with other residents before making a decision. The service does not offer intermediate care. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 7, 8, 9 & 10 & YA 9. The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed. This judgement has been made using available evidence including a visit to this service. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were viewed. All were person centred and included a full assessment that covered all aspects of the person’s personal, emotional, health and social support needs. Each individual was designated a key worker to assist with all aspects of their daily lives. The care plans were comprehensive and provided clear guidance to care staff. The care plans included pictures with simple language to ensure residents understanding. One resident with hearing and speech impairment was supported to understand their care plan through the use of Makaton, which was positive. Copies of service user questionnaires confirmed that residents were fully involved in developing their care plans and were happy with the support they received. The records included risk assessments demonstrating that residents were supported in taking responsible risks and that risks were minimised as far as possible. Senior care staff discussed how one resident was supported to take on more responsibility when shopping with guidance and support from staff so as to promote their personal development. Residents were enabled with staff support to have experiences outside their usual routines such as going on outings. Policies and procedures in place demonstrated the home’s commitment to minimising identified risks and hazards and promoting the health and safety of residents. Care plans included nutritional assessments with regular weight monitoring and appropriate action had been taken, i.e. referral to dietician, specialist diets provided. The records confirmed that residents received health care, for example by GPs, dentists, chiropody and opticians. This was also confirmed from completed surveys received from residents and their relatives. Relatives were unanimous in their view that the home provided good care. Comments received were “ I could not have found a better home”; my relative “is well looked after”. The home had a key worker system who supported residents on an individual basis and that was confirmed from the policy and care plans viewed. The home had medication policy and procedures that were available for staff guidance. The procedures provided clear guidance to staff enabling them to be confidant in their prctice. Medication was stored in a locked wall cupboard in the kitchen with keys held by the person in charge. A domestic type fridge was also available for storage of medication as relevant and temperatures of the fridge were monitored to ensure they remained at safe levels. However there were no monitoring of room temperatures being undertaken to ensure this did not exceed safe recommended levels (25°Centigrade). Medication was administered by senior care staff who had received appropriate training and confirmed from the records. Medication was supplied through a local pharmacy in individual containers and appropriate ordering and disposal 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 12 procedures were followed. Five residents records were inspected. All residents supplies were checked and confirmed that the prescribed medication was available. Medication administration records (MAR) were generally well recorded. However one medication dose had been inaccurately transcribed on the MAR sheet and the time of administration had been changed for another medicine but not recorded on the MAR sheet. Care files contained clear information and indicated each person’s preferred name. Staff were observed to treat residents with courtesy and dignity. Feedback from a health professional confirmed that residents’ privacy and dignity was always upheld when they visited. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15 The social and therapeutic activities provided enhanced residents’ daily lives and met their cultural expectations. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home had established good links with the local community, evidenced from the variety of social activities offered to residents. Each person living in the home has an individual ‘my life now’ a daily programme for the week that included leisure and educational activities. Those viewed detailed activities such as attendance at college, craft classes and shopping trips. Residents spoken with said they enjoyed going out on trips in the evenings with care staff to meet their friends at the local resource centre where they listened to music, enjoyed dancing and played bingo. The home accessed a bus for people with disabilities for trips out and for appointments at outpatients and dental clinics etc. Three residents attended a numeracy and literacy class each week at the local college. Staff had accompanied residents on two holidays since the previous inspection. From the photographs seen, residents had clearly enjoyed themselves. Residents spoken with said they could see their visitors in their own room or in the conservatory or lounge of the home. Feedback received from relatives confirmed they were welcomed into the home at anytime and were confidant in the care provided at Marine Approach. Marine Approach has a family type atmosphere with relaxed daily routines. Feedback from relatives confirmed they found the home an informal and caring environment for their loved ones. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to what clothes they wore, where they spent their day, meals, etc. Choices offered to residents were also confirmed from the care plans viewed and from discussion with residents. All of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them and could have their room decorated as they wished. From observation it was evident that residents were able to spend time alone rather than to take part in an activity. The records confirmed that nutritional needs were fully assessed on an individual basis and regular weight monitoring was undertaken. Menus was regularly reviewed with residents and choice and variety offered. Specialist diets and reducing diets were also provided as relevant to their needs. Meals were seen to be a family occasion with all residents eating together and helping to set the table and clear afterwards. Residents were seen to enjoy the lunchtime meal that looked appetising and comprised liver and onion casserole with leeks, cabbage, peas and carrots followed by desert. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 16 & 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that met regulatory requirements. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. There had been no complaints received by the home or CSCI since the previous key inspection. A record of all compliments was also maintained. The home had comprehensive policy and procedures for safeguarding vulnerable adults and a whistle blowing policy. The records confirmed that most care staff had received training in protection of vulnerable adults. A programme of updated in-house training had also commenced. From discussion with senior staff it was evident they understood what constituted abuse and that any allegations made would be appropriately referred and relevant procedures followed. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 19 & 26. Marine Approach was clean, well maintained and had a homely environment; residents’ rooms were individually furnished and equipped for their safety, comfort and privacy. This judgement has been made using available evidence including a visit to this service. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 17 EVIDENCE: A full inspection of the premises was made that included communal areas, bathrooms, residents’ rooms, the kitchen, and the laundry. Marine Approach had a homely environment, was furnished in accordance with the client group and was well maintained. The lounges were comfortably furnished and well decorated. Since the previous inspection a new conservatory had been built and some windows replaced. The records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had policies and procedures for infection control available for staff guidance and all staff had received training during induction and at regular updated sessions. The home was clean throughout with no malodorous smells. The utility/laundry room was domestic in size and well organised. There were two washing machines and one drier that were in working order. Hand washing facilities (liquid soap and paper towels) were provided for staff and protective clothing provided for their safety. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 27, 28, 29 & 30. People living at Marine Approach can expect to be cared for by experienced and caring staff who are known to them and who are employed in sufficient numbers to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a stable staff team with low staff turnover. There were five residents at the home. Care staff on duty comprised two senior care staff and one care assistant. Residents looked well cared for and were well supervised. Relatives who completed surveys were unanimous in their view that their loved ones were well cared for at the home. Feedback from surveys completed by residents indicated they were happy with care staff and looked upon them as their friends. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 19 The home had 2 care staff who were undertaking NVQ level 2 qualifications. There were none with an NVQ qualification. The percentage of staff with NVQ level 2 training was therefore less than 50 needed to meet the standard. The recruitment files of two recently employed staff were inspected. Both had evidence that the required checks had been obtained (two satisfactory references, CRB disclosures and POVA first checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. Both staff had received a statement of terms and conditions of employment. The training records seen confirmed that staff had completed training on infection control, fire safety, basic first aid and moving and handling during the last year. Training was also booked for first aid and food hygiene. Not all staff had received training in protection of vulnerable adults. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 31, 33, 35 & 38 Marine Approach is well managed with good health and safety standards that are well adhered to. This judgement has been made using available evidence including a visit to this service. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager/proprietor is a registered nurse in learning disabilities with current NMC registration. She has managed the home since registration and has many years experience in working in care of people with learning disabilities. Information received from the manager following the site visit confirmed that she had undertaken updated training relevant to the management of a care home for people with learning disabilities. The quality assurance programme was in early development. Questionnaires had been distributed to residents but not to relatives or other stakeholders. No report had been produced with the outcome of the surveys and there was no annual plan had been developed. There were no formal meetings but relatives confirmed they were kept fully informed on any issues. All residents had their own bank account and two residents managed their own finances with assistance. The manager was appointee for three residents and records were maintained of all incoming and outgoing payments. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual purses. Two residents’ records were inspected, and records, receipts and cash all balanced. The home had a health and safety policy and procedures. Records confirmed that all staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. evidence of gas safety, electrical safety etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment, fire alarms and emergency lighting, hot tap water temperatures, etc.). 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 22 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 3 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 23 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. 1. Standard OP9 Regulation 13(2) Requirement To ensure residents receive medication as prescribed any transcribing to MAR sheets must be accurate. To ensure staff are competent in their practice and residents are safeguarded, updated protection of vulnerable adults training must be provided for all staff. To ensure the home is run in the best interests of residents the quality assurance programme must be further developed and an annual plan produced. Timescale for action 21/12/07 2. OP30 13(6) 28/02/08 3. OP33 35 30/04/08 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 OP28 Good Practice Recommendations 50 of staff should achieve NVQ level 2. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 12 Marine Approach DS0000029503.V354981.R01.S.doc Version 5.2 Page 25 - 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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