Inspection on 25/09/07 for Marula House (Varley Road)

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marula House (Varley Road) 23/01/08

Marula House (Varley Road) 03/04/06

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

CARE HOME ADULTS 18-65 Marula House (Varley Road) 124 Varley Road Custom House London E16 3NS Lead Inspector Nurcan Culleton Unannounced Inspection 25th September 2007 11:30 Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 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 Marula House (Varley Road) DS0000065451.V351492.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 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. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marula House (Varley Road) Address 124 Varley Road Custom House London E16 3NS 020 7473 3818 TBA 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) Marula House Ltd Cleto Mapfumo Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Male whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding disability or dementia - Code MD The maximum number of service users who can be accommodated is: 2 3rd April 2006 Date of last inspection Brief Description of the Service: Marula House is a two-bedded care home for men with mental health support needs. The home additionally caters for men who have an accompanying learning disability. The home is owned and managed by a private individual who owns a similar home in the Canning Town area. This home was registered on 16th November 2005. Residents have the opportunity to live an independent lifestyle within a supportive environment. The premises is a terraced property, which blends easily into the neighbourhood and presents as a family home. There is a communal lounge with satellite television and a garden with a small patio area and garden furniture. All bedrooms are located upstairs. The home does not have a passenger lift; therefore it is unsuitable for service users with mobility needs. Marula House is off the A13 road and unrestricted street parking is available. Local amenities include a parade of local shops in Prince Regent Lane. The Custom House and Prince Regent Stations are within walking distance. Buses are also available from Prince Regent Lane. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 25th September 2007 in the presence of the Assistant Manager. The house is currently full with two residents living in the house, though one resident was out during the inspection. The outcome of this inspection follows an examination of the files of both residents living in the home, a random sample of staff files, a range of records and documents related to the health and safety practises of the home and an inspection of the premises. The views of the one resident present in the house have been taken into account throughout the inspection. The inspector was unable to view the bedroom of this resident as permission was not granted from them on the day. An Annual Quality Assurance Assessment (AQUAA) received from the home prior to the inspection has also been taken into account during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvements are still required in the majority of areas where shortfall were identified at the last inspection. Risk assessments remain inadequate as they do not comprehensively identify areas of risk to residents and actions to minimise risks. Care plans do not fully identify residents’ needs and actions in response to meeting needs. Residents’ financial records are still not accurately maintained. Staff do not have first aid certificates as previously required. Water temperatures regularly exceed the recommended safety level without any plan in place to redress this. Residents’ files are and records are poorly maintained. Key documents concerning the care and wellbeing of residents, including their care plans and activities charts are not updated and not consistently signed or dated by the author or individual resident. Some policies as specified at the last inspection are not still in place. There is a paucity of Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 6 evidence and information about staff training. Supervision of staff is infrequent and a staff appraisal system is not in place to address the ongoing development needs of staff and their ability to meet the needs of the residents. 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. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Marula House has the capacity to meet individual residents’ needs and works well with health and social services professionals to assess resident’s ongoing needs and wishes. EVIDENCE: Prospective users and people using the service have access to information about the home through the Statement of Purpose and Service Users’ Guide. However these were not available on the day as they were in the process of being updated to incorporate the recommendations given at the last inspection. These are that the Statement of Purpose should provide further details of the fire precautions. The useful telephone number list in the Service User Guide should be completed and the contact number for Social Services should be included. Residents’ needs are assessed by their local authority prior to their admission and through a pre-admission assessment completed by Marula House. The assessment process is multi-disciplinary and includes health and social care Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 9 professionals and previous care providers. Assessments are signed by the residents and dated. The home has a referral and admission policy and eligibility criteria. Emergency admissions are not accepted. The eligibility criterion clearly identifies the dependency levels the home can sufficiently care for. The home demonstrates its capacity to meet the residents’ individual needs, including their ethnic, cultural and religious needs, as identified in their assessments. A resident attended an Afro-Carribean club until recently, as arranged by Mencap (ending as a result of his personal circumstances as recommended by Mencap). Residents are supported and have the choice of attending church in their vicinity or in another area of their choosing, for example, to attend a service alongside their family. One to one sessions take place with residents however they do not take place as frequently as according to the homes’ policy. Records in files, including staff observations, and minutes of team meetings demonstrate that staff have good insight into residents’ needs. A behaviour management chart is used in conjunction with behaviour management guidelines and a positive reinforcement programme for one resident. This residents’ likes and dislikes are also recorded in their file, assisting staff to have an improved understanding of the residents’ holistic needs. Minutes of a strategy meeting in one residents’ file outline that the number of incidents reported to CSCI had significantly reduced following admission to the home. The placement was described as providing stability to the resident compared with his previously unsettled placement history and aggressive outbursts. Contracts are available in residents’ files agreed between the home and Local Authority. However residents also sign up to a contract which outlines the house rules and expectations. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6-10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home works well together with health and social care professionals to regularly review residents’ needs. Residents care plans are in place but their care plans need to improve. Residents’ risk assessments are inadequate. EVIDENCE: Residents’ needs are regularly reviewed including health and social care professionals. Signed and dated progress reports are available for each resident, ensuring that a system is in place to monitor residents’ needs on an ongoing basis and that an overview of their progress is maintained. Residents each have care plans, however they are disorganised and inadequately address resident’s needs. Identified needs in the body of care plans do not correspond well to the general headings of the care plans. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 11 There is, in addition, a duplication of specified needs under other headings within the same care plan, making the care plan disjointed. One part of a care plan was not signed or dated at all. Financial assistance is individually considered involving family members, however one residents’ need for financial assistance is not included in his care plan. A local authority easy read care plan summary is available in the file of a resident with a learning disability. Residents voice their views in one to one sessions and in regular house meetings and through their advocates such as from Mencap. A previously made requirement has failed to be met to ensure comprehensive and adequate risk assessments of service users’ needs. Risk assessments remain incomplete, giving an overview of circumstances leading to increased risk behaviour only. The level of risk is not stated and there are no strategies to identify how to minimise risk. A community nurse had completed a risk assessment and control measures for the management of one residents’ epilepsy in March 2006. There is no evidence that this has been reviewed since or whether this management plan is still current. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to engage in activities of their own choosing. However poorly maintained records in residents’ files do not reflect their current programmes. The menu could improve further to provide more balanced meals. EVIDENCE: Residents are assisted with their identified personal care needs, such as assistance with bathing. Activity charts are developed to ensure that a weekly programme is scheduled for each individual. However as one form seen is not signed or dated, it is not possible to know whether the activities are still current. Until recently, one resident attended a social club for people with mental health needs, with the support of Mencap. However the resident has not attended the centre for some months and his activities chart has not been Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 13 updated. There are two other activity charts for the same resident. One is torn in the sleeve of the file and the other was found loose in the file of the other resident. Residents’ activities reflect their personal choices, needs and resources available. One resident likes to walk in the local area twice daily with staff. Residents are currently engaged in a variety of activities, including attendance at a luncheon club; pub lunches and meals out. Records show that residents are encouraged to use facilities in the community, such as the local leisure centre for use of the gym and swimming pool, however residents may be reluctant to engage. Currently one person has a temporary job helping in a fun fair. The home encourages residents to pursue college courses and of their choice and to gain qualifications, such as an NVQ in Horticulture acquired by one resident. However activity charts do not reflect current activities for each person as they are not routinely updated following any changes. Monthly residents meetings ensure that people have a regular forum where their views can be obtained as regards issues arising in the home or their personal activities. Residents maintain contact with family and have developed intimate relationships, for which support is available, if necessary, to access sexual health counselling or through one to one key work or support sessions. Residents choose their meals, however the menu consists of meals served with chips on two to three days a week in some weeks and therefore lack sufficient variety and balance in those weeks. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18-21 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individual personal and health needs are generally promoted at Marula House. However tools used to monitor health needs must be consistently used and form part of a residents’ overall care plan. Medication training for staff must be evidenced. EVIDENCE: Progress reports and case file records show that residents have access to a range of health care appointments, including the GP, dentist and optician, though despite encouragement from staff, some residents sometimes fail to keep their appointments. Care Programme Approach reviews are attended by psychologists, psychiatrists, community nurses and social workers. Contact is maintained with the Learning Disability Partnership in the borough. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 15 However the residents’ care plans and recording procedures are poor in identifying the home’s response to meeting identified health needs. One persons’ weight chart has been inconsistently completed. Whilst his care plan includes a goal to loose weight, the completion of this weight chart for use as a monitoring tool is not included in the care plan. The Boots dossette system is used to administer medication. The medication administration record is appropriately completed. However whilst all staff are said to have completed medication training, there is no evidence to show that in-house or external training has been undertaken. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Marula House is unable to demonstrate that it has in place an effective procedure for dealing with residents’ complaints. People using the service continue to need better protection by the home’s financial recording practices. EVIDENCE: Complaints are responded to, however complaints recording is inadequate. The complaints book contains one complaint made by a resident. However correspondence in one residents’ file shows another complaint made by a Mencap support worker on behalf of this resident. The complaints book contains no record that the outcome of the complaint has also been communicated to the resident as well as to the person making the complaint. The home has an adult protection policy and procedure in addition to the local authority multi-agency policy and procedures. A strategy meeting including the manager of the home has investigated concerns expressed by a relative and an appropriate management plan has been developed to address these. Residents’ petty cash and the balance of monies checked were accurate at the time of inspection, however staff have not followed the homes’ recording procedures when handling one residents’ money for the latest five occasions and the resident had therefore not signed against these transactions. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a comfortable, domestic type environment providing suitable accommodation to meet residents’ needs. The home could benefit from more adornments to further promote a homely atmosphere. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 18 EVIDENCE: The inspector lacked residents’ permission and therefore access to inspect residents’ bedrooms on this occasion. However bedrooms have been inspected on previous occasions for the current residents. All residents have single rooms. Residents personalise their bedrooms to reflect their individual tastes and bring in their own personal effects, including televisions, music systems, videos and DVD players. The modern fitted kitchen incorporates a dining area and doors lead out to the garden. The garden has a patio section and a lawn with garden furniture. The communal lounge is comfortable and suitable for shared activities. However the home would benefit from more pictures or adornments in the lounge and in the hallway to contribute further to the homely atmosphere. Pictures and plants contribute to the homely atmosphere. Satellite television, video, music entertainment system, board games, books and newspapers are available for the residents. This home is unsuitable for prospective service users with mobility needs, as all bedrooms are on the first floor and a passenger lift is not available. The washing machine is for domestic use and is located in the kitchen. Separate laundry facilities are not provided. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Marula House has adequate staffing however training and recruitment shortfalls continue to affect the home’s ability to demonstrate that residents fully benefit from an effective staff team. EVIDENCE: Job descriptions are available in staff files. The Assistant Manager spoken to had a clear understanding of their role and is currently undertaking the Registered Managers’ Award. The Assistant Manager has had previous relevant work experience prior to taking up his position in the home. Whilst there is evidence of some staff training, such as moving and handling, food hygiene, care assistant and mental health, staff training records are not comprehensive and in some files and is very scant information in other files, showing, for example, only an NVQ certificate and no other evidence of training. There are four permanent employees. One staff member per shift and one wake-in staff Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 20 member at night. Staff meet regularly on a monthly basis to discuss and share issues relating to each resident. Minutes of these meetings demonstrate that staff have good knowledge of individual residents’ needs. Staff files are, for the most part, in good order. With the exception of one staff members’ file which contains two references, completed by the same person with identical information and handwriting, though they have different signatures. A satisfactory explanation to account for this could not be offered either in the file or verbally at the time of the inspection. The Assistant Manager supervises all staff and the Registered Manager supervises the Assistant Manager. However the home is unable to demonstrate that staff are adequately supervised as records show that staff supervision sessions are overdue. Staff have not yet received annual appraisals to support their ongoing development to ensure they are sufficiently able to carry out their support work. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the manager is suitably qualified and experienced, there are significant shortfalls and unmet previous requirements. Further improvements continue to be needed to promote the health and safety of residents and in record keeping. More effective management is required to ensure that practises within the service operate consistently and in line with the home’s policies and procedures. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Provider/Manager was not present during the inspection. The Registered Provider/Manager has eight years experience in the residential care field, owning another care home in the vicinity and is a registered mental health nurse. At the last inspection, the Registered Provider/Manager was completing the Registered Managers Award and evidenced that they had the necessary skills and experience required for their role. The Assistant Manager demonstrably has a good relationship with the resident in the house who was present during the inspection. The resident was able to address their needs and concerns to the Manager. Staff meetings cover a range of issues, including management, service users’ needs, policies, procedures and service provision. The home has a quality assurance policy and quality assurance systems are in place. Residents’ satisfaction surveys state that residents feel safe and secure in the home; that the overall facilities are excellent in the home; there are no complaints or that their complaints have been appropriately dealt with by staff; their privacy is respected and both residents stated that overall, the standard of service is excellent. However these surveys are not dated therefore it was not possible to know when they had been completed. Policies and procedures are available in the home, with the exception of the discharge policy and managing incontinence, as required at the previous inspection. Record keeping issues have been highlighted in previous sections of this report. Service users rights and best interests must be safeguarded by the home’s record keeping procedures. There was no index at front of one service users’ file making access to information more difficult. Further attention to detail could be given in records generally, for example one residents’ missing person profile gave the name of his GP but no contact details for the GP. Health and safety certificates for gas, electrical wiring and PAT testing are available, as are the alarm test and fire drill records. However daily water checks show that the water temperatures regularly exceed the recommended temperature of 43 degrees, reaching temperatures such as 55 degrees. The home has failed to meet a previous requirement stating that a record must be kept action taken when the water temperature is above 43 degrees. In addition, staff training records do not evidence that all staff have appropriate first aid training. The Assistant Manager informed that he had received basic first aid training. However evidence of first aid training approved for staff working in a residential setting, particularly when lone working, must be available for all staff. be course. The home must ensure that its health and safety practises are safe at all times for the safety and protection of residents. A water safety test is recommended in line with Health and Safety Executive advice for small homes. A current employers’ liability insurance is available. Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 23 Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 N/A STAFFING Standard No Score 31 3 32 2 33 3 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 1 1 LIFESTYLES Standard No Score 11 3 12 1 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 1 1 1 1 1 N/A Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 25 yes 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 Standard YA6 Regulation 15(1)(2) Requirement Ensure adequate care plans are in place which clearly identify residents’ needs. Ensure action plans are clearly identified in residents’ care plans in response to meeting their needs. Ensure all care plans are signed and dated by its author, and where appropriate, by the resident. All residents must have appropriate and comprehensive risk assessments in place, which are reviewed and updated as required. The previous timescale of 01/ 06/06 has not been met. 3. YA12 16(2)(m) Ensure residents’ activities are accurately recorded and updated following any changes. 14/12/07 14/12/07 Timescale for action 14/12/07 15(1)(2) 15(1)(2) 2. YA9 13 (4) (c) Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 26 4. YA20 13 (2) 5. YA23 17 (2) Provide evidence that all staff have received satisfactory medication training, whether inhouse or external, Ensure residents’ financial records are accurately maintained. The previous timescale of 01/05/06 has not been met. 14/12/07 08/11/07 6. 7. 8. YA34 YA35 YA35 19 18(1) 13 (4) Ensure there are two satisfactory references for all employed staff. Maintain a comprehensive record of all training undertaken by all staff in the home. All staff must have current first aid certificates. The previous timescale of 01/09/06 has not been met 23/11/07 14/12/07 21/12/07 9. 10 11. YA36 YA39 YA41 18(2) 24 17 (1) Ensure all staff are appropriately supervised. 23/11/07 Ensure quality assurance surveys 23/11/07 for residents or other persons are dated. 23/11/07 Residents’ files must be well maintained. The timescale of 01/05/06 has not been met. All forms and charts related to residents’ needs and activities must be signed by the author, and where appropriate the resident, and dated. 12. YA42 13 (4) The home must record the outcome and action when the water temperature is above 43 degrees. The timescale of 01/05/06 has not been met. 08/11/07 Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA3 YA17 Good Practice Recommendations The frequency of one to one sessions with residents to take place as according to the homes’ policies and procedures. Further encourage residents’ to eat more varied, nutritious and balanced meals. All Complaints and their outcomes to be recorded in the complaints book, including evidence that the outcome of the complaint has been communicated to the resident. Put in place more pictures or adornments in the lounge and in the hallway to contribute further to the homely atmosphere. Ensure all staff have annual appraisals. Ensure that a discharge policy and disposal of clinical waste/managing incontinence is available. The timescale of 01/08/06 has not been met. 7. 8. YA41 YA42 Ensure there is an index at the front of all residents’ files for efficiency and ease of access to information in files. Obtain a water safety certificate is available to ensure the safety of water against Legionnaires Disease, as recommended by the Health and Safety Executive. 3. 4. 5. 6. YA22 YA24 YA36 YA40 Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Marula House (Varley Road) DS0000065451.V351492.R01.S.doc Version 5.2 Page 29 - 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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