Inspection on 03/04/06 for Marula House (Varley Road)

This inspection was carried out on 3rd April 2006.

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 found no outstanding requirements from the previous inspection report, but made 11 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) 25/09/07

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

CARE HOME ADULTS 18-65 Marula House 124 Varley Road Custom House London E16 3NS Lead Inspector Sharon Lewis Announced Inspection 3rd April 2006 10:00 Marula House DS0000065451.V286084.R01.S.doc Version 5.1 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 DS0000065451.V286084.R01.S.doc Version 5.1 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 DS0000065451.V286084.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marula House Address 124 Varley Road Custom House London E16 3NS TBA 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) Mr Cleto Mapfumo Mr Cleto Mapfumo Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 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 Mr Cleto Mapfumo owns the home. This home was registered on 16th November 2005. Mr Mapfumo also owns a similar care home in the Canning Town area. Service users 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. Service users have access to 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 DS0000065451.V286084.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection was the first Inspection to be undertaken since the home was registered in November 2005. The Inspection commenced on a Monday morning and lasted approximately five and quarter hours. The Inspector spoke individually to both service users currently living at the home. Both service users related they were happy living at the home. Individual discussions were also held with the Registered Provider/Manager and the Senior Support Worker on duty. Comment cards were received from the two service users, a relative, three staff members and four health and social care professionals. The majority of feedback was positive. Professionals highlighted that “Personal and professional contact with staff have always been professional and useful. I am impressed by the relationships staff have with service users and with the insight staff show about the service users difficulties”. Negative comments related to the challenging needs previously reported to the Commission for Social Care Inspection. Service users files medication and medication administration records, policies and procedures, all health and safety records and other relevant documentation were examined. A tour of the premises was also undertaken. The Inspector would like to thank all service users and staff members for their assistance with this Inspection. What the service does well: Service users related they were happy living at the home, their independence was promoted and they had developed good relationships with staff and management. Service users benefit from residing in a supportive, warm, family atmosphere Service users assist with preparing snacks, meals and take responsibility for housekeeping tasks. This includes washing up, shopping, laundry and housework. Observation and documentation evidenced positive staff interactions. Staff had built good relationships with service users and their families. Service Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 6 users regularly visit and keep in touch with their respective families. Evidence was seen of families being kept informed of all developments, being involved in care review meetings and enjoying meals at the home. Service users engage in their local community by going shopping, to the bank, pharmacy, gym, luncheon club, cinema, eating out and enjoying regular walks. During the Inspection service users were observed going to the gym and going to the local shop with staff. Service users are encouraged to make their own decisions, exercise their autonomy and individual rights. Service users have regular one to one key work meetings which enables them to work on their goals, address any concerns and behavioural issues. Advocacy involvement is actively encouraged and the home has built up good relationships with health and social care professionals. What has improved since the last inspection? What they could do better: During this Inspection eleven legal requirements and three recommendations were highlighted. Service users must benefit from the home’s risk management systems. The home must ensure risk assessments are fully completed, comprehensively address all areas of risk and are up-to-date. Service users must be better protected by the home’s record keeping practices. Staff must ensure medication administration records are appropriately maintained. The home must ensure service users financial records and files are accurately maintained. The home must ensure all accidents are recorded in the accident book. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 7 Service users must be protected by the home’s health and safety practices. All staff must have current first aid certificates. A fire risk assessment must be produced. The home must record the outcome and action when the water temperature is above 43 degrees. The home must evidence that service users are be supported by a safe and effective staff team. The Registered Provider/Manager must ensure that newly appointed staff do not work unsupervised without a new POVA First check or CRB clearance. A written record must be kept of all staff inductions. A Discharge policy, Access to Files, Disposal of clinical waste/managing incontinence and Dying policy must also be produced. 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. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 8 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 DS0000065451.V286084.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Marula House has the necessary documentation, policies and procedures, which assist prospective service users in deciding if the home can meet their needs. Service users would further benefit from the updating of the Statement of Purpose and Service User Guide. EVIDENCE: Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 10 The home has produced a Statement of Purpose that details the aims, objectives and philosophy, service and facilities and terms and conditions. Service users have their own guide, which summarises the Statement of Purpose. The Statement of Purpose maintains, “We work within a framework of enabling and empowering our residents, encouraging self responsibility and nurturing a climate of informed choice”. It is recommended that both the Statement of Purpose and Service User Guide be further updated. 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. Service users’ files evidenced that service users were admitted to the home only after a full assessment had been undertaken. The assessment process is multi-disciplinary and includes health and social care professionals and previous care providers. The home has a referral and admission policy and eligibility criteria. Emergency admissions are not accepted. The eligibility criteria clearly identifies the dependency levels the home can sufficiently care for. The Statement of Purpose confirms that care provision is “based on the thorough assessment of needs and the systematic and continuous planning of care for each resident”. Service users files evidenced that a pre-admission assessment is always completed by the home. Service users individual profiles also indicate their likes and dislikes in relation to food, activities and support needs. Service users files and policies and procedures evidenced that service users had a series of opportunities to visit the home prior to moving in. Service users were accompanied by relatives or their social worker. Visits were gradual and included an orientation of the local area. Service users files evidenced that their placing authorities had contracts with the home, which detailed the terms and conditions of the placement. The items specified in the National Minimum Standard 5.2 are detailed in the Statement of Purpose and Service User Guide. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 – 10 Service users individual needs and choices are promoted at Marula House. Risk management and care planning systems however must be improved. EVIDENCE: Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 12 Individual care plans have been developed for each service user, which incorporates their placing authority care plan. Care planning addressed service users support, mental health needs and family contact needs. It is recommended that individual care plans are further developed to comprehensively address the full range of service users needs. Care plans should detail the items addressed in National Minimum Standard 2.3. Service users’ files evidenced that their care plan was reviewed monthly by the home and during review meetings with the consultant psychiatrist, other professionals and family members. Service users are allocated key workers who provide guidance, support and monitor their progress. Other staff members are additionally appointed to assist with key working duties. The home evidenced that regular key work sessions were held. The home demonstrated that staff were actively working with service users to address their individual needs, behaviour and goals. Service users are able to participate in the day to day running of the home through monthly residents meetings, discussions with staff and key work sessions. The home evidenced through documentation, discussion and observation that service users are treated with respect, dignity and listened to. Advocacy services are also appropriately involved in promoting service users rights. Service users are supported to take risks as part of an independent lifestyle. A risk assessment policy and risk checklist is in place. Evidence was seen that the balance of individual choice and risk is considered and promoted. Management guidelines and plans are in place for managing areas of challenging behaviour. Files evidenced that risk assessment were not routinely updated after incidents and in one case was not fully completed. The home must ensure risk assessments are fully completed, comprehensively address all areas of risk and are up-to-date. A Confidentiality policy has been produced. Confidentiality is also addressed in the Record Keeping policy. Service users’ files were securely stored in a locked cupboard in the Manager’s office. Service users know that information about them is handled appropriately and that their confidences are met. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 - 17 Each service users lifestyle needs are individually promoted at Marula House. EVIDENCE: Service users have opportunities for personal development within the home. Spiritual needs are promoted through regular church attendance and visits to the home by a clergy person. Service users’ files, observation and discussions with service users and staff evidenced that independent living skills are actively encouraged. Service users assist with meal preparation, shopping, laundry and housework. Service users responsibility for house keeping tasks is specified in their individual plan. Opportunities to enable service users to take part in age, peer and culturally appropriate activities are in progress. Service users are respectively awaiting a place on a college course and at a day centre. Documentation, discussion with service users and staff evidenced that service users are part of the local community. Service users engage in their local community by going shopping, to the bank, pharmacy, gym, luncheon club, Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 14 cinema, eating out, enjoying regular walks and attending the local leisure centre. All service users have a benefit from a Freedom Pass, which enables them to travel freely by public transport. During the Inspection service users were observed going to the gym and going to the local shop with staff. Service users engage in a range of leisure activities within the home and outside. An annual activity programme has been developed. A part-time Activities Co-ordinator has been recruited and is expected to start work in May 2006. Indoor activities include board games, current affairs discussions, provision of newspapers and satellite television. Service users choose their annual holiday and are looking forward to their forthcoming holiday to Great Yarmouth. Service users further entertained themselves through watching dvds and listening to music. Service user and staff discussions and documentation evidenced that service users maintain family and personal relationships. This included visits to their respective families, visits by family to the home and telephone contact. Relatives enjoy meals at the home and staff had built good relationships with service users families. Evidence was seen of families being kept informed of all developments and being involved in care review meetings. The home demonstrated that service users’ rights are respected and responsibilities recognised in their daily lives. Birthdays are celebrated; A service user informed the Inspector of their recent birthday celebration. Service users were observed during the Inspection exercising their individual choice and participating in their own daily routines. Documentation and observation evidenced that service users choose when to get up, get dressed, and be alone or in company, and when not to join an activity. The home evidenced that meals are healthy, nutritious and reflected various cultures. Plans are in place to provide a meet a specific cultural need. Fresh fruit is readily available. Service users additionally have the opportunity to have a takeaway meal and eat out. Kitchen premises were inspected and were found to be clean. Fridge and freezer temperatures are monitored and recorded daily. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 – 21 Service users personal and health needs are generally promoted at Marula House. Greater care however must be taken when maintaining medication administration. EVIDENCE: Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 16 Service users receive personal support in the way they prefer and require. Currently service users do not require assistance with personal care. Times for getting up/going to bed, baths, meals and other activities are flexible and dependent on service users needs and preferences. Service users choose their own clothes and their appearance reflects their age and personality. Staff ensure consistency and continuity of support for service users through designated key workers. The home demonstrated that service users’ physical and emotional needs were met. Staff escort service users to their health appointments, where necessary. Service users are supported to access NHS healthcare facilities in the locality. These include the dentist, optician, chiropodist, psychiatric services and specialist health services. Files additionally evidenced that service users also benefit from alternative therapies, which included reflexology/relaxation. Medication and medication administration records were examined. Medication was found to be stored in a locked cupboard. Medication administration records evidenced four discrepancies were gaps were noted. PRN (when required) medication must be consistently recorded to correspond with the incident and reasons for administration. Staff must ensure medication administration records are appropriately maintained. Service users must be protected by the home’s medication procedures. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 - 23 Marula House effectively promotes service users rights and complaints. Service users must be better protected by the home’s financial recording practices. EVIDENCE: The home has produced a complaints policy. There has been one complaint during the last 12 months. The Inspector was satisfied that complaints are appropriately managed. Service users were aware of the complaints procedure and regularly raised concerns with staff. The home has an adult protection procedure, whistle blowing procedure, violence/aggression and restraint policy. Service users financial records were examined. Service users are encouraged to save. Unaccounted for receipts were found which were not detailed in financial records. The home must ensure service users financial records are accurately maintained. Service users must be protected by the home record keeping procedures. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30 Marula House provides service users with a comfortable and homely environment. EVIDENCE: Marula House is a terraced property, which blends easily into the neighbourhood and presents as a family home. The home was found to be bright, airy, clean and free from offensive odours. The home provided sufficient and suitable lighting and heating. The home 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 DS0000065451.V286084.R01.S.doc Version 5.1 Page 19 All service users have single rooms. Service users’ rooms were personalised to reflect their individuality. Personal items included televisions, music systems, videos and dvd players. Service users can bring their own furniture and can decorate and personalise their rooms subject to fire and safety requirements. Shared spaces complement and supplement service users’ individual rooms. 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 well decorated. Pictures and plants contribute to the homely atmosphere. Satellite television, video, music entertainment system, board games, books and newspapers are available for service users. 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 DS0000065451.V286084.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 - 36 Marula House has adequate staffing however first aid, recruitment and employment shortfalls must be addressed to ensure service users fully benefit from an effective staff team. EVIDENCE: Staff evidenced that they knew and supported the main aims and values of the home. This included their ways of working, respective roles and responsibilities. Discussions and observations demonstrated that staff respect service users and have attitudes and characteristics that are important to them. Staff were observed to have good communication skills and demonstrated an awareness of service users’ individual needs. Staffing rotas evidenced that one member of staff is on duty at all times. Staff shifts are Early 7am – 2.30pm, Late 2.15pm – 9.15pm and Night 9pm7.15am. Staffing is additionally complemented by Manager support, Monday to Thursday between 9am - 5pm. Emergency on call arrangements are in place. Staffing was sufficient to meet the individual and collective needs of service users. Staff general training and National Vocational Qualification (NVQ) training is in progress. Over 50 of staff have achieved the NVQ Level 2 qualification or Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 21 above. The Senior Support Worker is currently undertaking the NVQ Level 4 in Management and Care. The home must however ensure all staff have current first aid certificates. As staff frequently work solely, service users must be supported by staff able to respond in a medical emergency. The home has a recruitment policy and procedure. Three personnel files were examined. Files are maintained in accordance with Schedule 2, Care Homes Regulations 2001. Examination of files evidenced that the home had started new staff members with their previous Criminal Records Bureau (CRB) checks. The Registered Provider/Manager must ensure that newly appointed staff do not work unsupervised without a new POVA First check and CRB clearance. Service users must be protected by the home’s recruitment practices. Examination of records evidenced that staff received regular supervision. Supervision covered the home’s philosphy and aims; monitoring of work with individual service users; support and professional guidance; and identification of training and development needs. Records evidenced that most staff had received a written induction. The induction record for one member of staff however was outstanding. The Registered Provider/Manager must ensure a written record is kept of all staff inductions. The disciplinary procedures should also be updated to include Protection of Vulnerable Adult (POVA) referral, in reference to gross misconduct. Service users must be protected by the home’s employment practices. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 - 43 Marula House is well managed and promotes an open, accessible atmosphere. Further improvements are needed in health and safety, record keeping and policy development. EVIDENCE: Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 23 The Registered Provider/Manager is a registered mental health nurse with eight years full time nursing experience. The Registered Provider/Manager has seven years experience in the residential care field, owning another care home in the vicinity. The Registered Provider/Manager is currently completing the Registered Managers Award and evidenced that they have the necessary skills and experience required for their role. The process of managing the home was seen to be open and transparent. Service users had a good relationship with the management and stated they would address any concerns with them. Staff interviewed related they feel valued and are able to use their initiative. Staff meetings were seen to cover a range of issues, including management, service users, policies, procedures, and service provision. The home has a quality assurance policy and quality assurance systems are in place. An annual service development plan has been produced by the home. Service users questionnaires have been developed and there are plans to consult with professionals and relatives twice yearly. The home has produced policies and procedures in accordance with Appendix 3, National Minimum Standards for Adults 18-65. The following however remain outstanding and must be produced; Discharge policy, Access to Files, Disposal of clinical waste/managing incontinence and Dying policy. All service users files were examined. Records were signed by staff and promoted service users’ independence and individuality. Two discrepancies were found in relation to information about another service user being recorded in the wrong file and the incorrect date being written. Service users files must be accurately maintained. The correct date must be recorded. A record of all meals eaten must also be consistently kept. Service users rights and best interests must be safeguarded by the home’s record keeping procedures. The home evidenced all health and safety certificates are in place. Fire safety was examined. The home evidenced that regular fire drills were held and the fire alarm system is tested every week. A fire risk assessment however must be produced. Service users must be protected by the home’s fire safety practices. Accidents and incidents records were examined. The home must ensure all accidents are recorded in the accident book. Water temperature are tested regularly, the home must record the outcome and action when the temperature is above 43 degrees. Service users must be protected by the home’s health and safety practices. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 24 The financial plan and budget was examined. The home endeavours to run a financial viabie quality service. The home’s insurance policy was examined and found to provide adequate insurance cover. Lines of accountability within the home are clearly understood by staff and service users. Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 25 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 2 2 2 3 Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 26 N/A 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 YA9 Regulation 13 (4) (c) Requirement Timescale for action 01/06/06 2. YA20 13 (2) The home must ensure risk assessments are fully completed, comprehensively address all areas of risk and are up-to-date. Staff must ensure medication 01/05/06 administration records are appropriately maintained. PRN (when required) medication must be recorded consistently to correspond with the incident and reasons for administration. The home must ensure service users financial records are accurately maintained. The Registered Provider/Manager must ensure that newly appointed staff do not work unsupervised without a new POVA First check or CRB clearance. All staff must have current first aid certificates. The Registered Provider/Manager must ensure a written record is kept of all staff inductions. A Discharge policy, Access to Files, Disposal of clinical waste/managing incontinence and Dying policy must be DS0000065451.V286084.R01.S.doc 3. 4. YA23Y YA34 17 (2) 19 (4) (b) 01/05/06 01/05/06 5. 6. 7. YA35 YA35 YA40 13 (4) 18 (1) (c) 12 (1) 01/09/06 01/06/06 01/08/06 Marula House Version 5.1 Page 27 produced. 8. 9. 10. 11. YA41 YA42 YA42 YA42 17 (1) 23 (4) 17 (1) (a) 13 (4) Service users files must be accurately maintained. A fire risk assessment must be produced. The home must ensure all accidents are recorded in the accident book. The home must record the outcome and action when the water temperature is above 43 degrees. 01/05/06 01/06/06 01/05/06 01/05/06 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 YA1 Good Practice Recommendations 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. Individual care plans should be further developed to comprehensively address the full range of service users needs. The disciplinary procedures should be updated to include Protection of Vulnerable Adult (POVA) referral, in reference to gross misconduct. 2. 3. YA6 YA36 Marula House DS0000065451.V286084.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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. 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