Inspection on 15/06/07 for Magnolia House, Exmouth

This inspection was carried out on 15th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Magnolia House, Exmouth 18/08/09

Magnolia House, Exmouth 20/08/08

Magnolia House, Exmouth 26/06/06

Magnolia House, Exmouth 22/02/06

Magnolia House, Exmouth 13/07/05

Magnolia House, Exmouth 14/02/05

Magnolia House, Exmouth 13/07/04

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

CARE HOMES FOR OLDER PEOPLE Magnolia House, Exmouth 40 - 42 Morton Road Exmouth Devon EX8 1BA Lead Inspector Sue Dewis Unannounced Inspection 15 June 2007 09:30 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 Magnolia House, Exmouth DS0000021974.V336140.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. 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. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Magnolia House, Exmouth Address 40 - 42 Morton Road Exmouth Devon EX8 1BA 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) 01395 264338 01395 275824 t_keough@btconnect.com Ashgrove Care Company Limited Mr Thomas Duncan Keough Care Home 25 Category(ies) of Dementia (25), Physical disability over 65 years registration, with number of age (25) of places Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 Brief Description of the Service: Magnolia House provides personal care for up to 25 older people who may also have a dementia type illness and/or a physical disability. It is situated close to the seafront and not far from the town centre of Exmouth. The property was formerly three large terraced houses, which have been converted and adapted. Accommodation is arranged over three floors, with a passenger lift giving access to all floors. All rooms are for single occupancy only with 12 having en suite facilities. There are two lounges and two dining rooms on the ground floor. There is a small outside sitting area available to the front of the building and a small courtyard area to the rear which has been made accessible to service users. Parking is on the road. Information received from the home indicates that the current fees are £372£441 weekly. Services not included in this fee are hairdressing, chiropody, newspapers and magazines. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk CSCI Inspection reports are available upon request with the summary of the latest report being given to prospective residents. Magnolia House, Exmouth DS0000021974.V336140.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 over approximately nine hours, one day in the middle of June 2007. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire and an Annual Quality Assurance Assessment (AQAA), information from which was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. As part of this, questionnaires were sent out to 9 people living at the home, 11 health and social care professionals (including GPs and care managers) and 9 staff. At the time of writing the report, responses had been received from 2 people living at the home, 2 health and social care professionals and 3 staff. During the inspection 2 people living at the home were spoken with individually, 3 in a group setting, and 1 person’s representatives. People living and working at the home were also observed interacting throughout the day. We also spoke with 5 staff, the care manager and the owner. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files What the service does well: The home provides a warm and friendly environment, and good relations were witnessed between those who live and work at the home. There are good admissions and care planning procedures that assure individuals their personal and healthcare needs can be met. There are good recruitment procedures and staff are well trained and know their duty to report bad practice. There is a clear and simple complaints procedure and the owner generally ensures safe health and safety practices. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 6 The owner submitted a full and detailed AQAA (Annual Quality Assurance Assessment), that showed a realistic assessment of the quality of the service provided. What has improved since the last inspection? What they could do better: Though many areas for improvement were identified, none were deemed to pose a significant risk to the health, safety and well being of those living and working at the home. Staff should always follow the home’s procedure for the administration of medication. Privacy and dignity is not always respected and the home should ensure steps are taken to improve this area, especially ensuring people are appropriately dressed at all times. Improvements to the en-suite facilities and locks on doors would also improve privacy. All areas should be free of offensive odours at all times. Staffing levels do not always provide for individuals to have real choices in their daily lives and the levels of activities and outings could be improved. Doors on upper floors should meet fire authority requirements and accident records should be regularly reviewed and risk assessments updated if necessary. The quality assurance system should ensure that all aspects of care at the home are regularly reviewed in consultation with interested parties and the subsequent report made available to everyone. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 7 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. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure ensures that there is a proper assessment prior to people moving into the home. Intermediate care is not provided at Magnolia House. EVIDENCE: The files of three people living in the home were inspected. The two most recently admitted people each had thorough pre-admission assessments completed prior to them moving into the home. They contained comprehensive information that determined whether the home could meet the assessed needs of the individual. The third file looked at was of someone that had been at the home for many years and the information was not so detailed. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 10 The care manager visits people thinking of moving into Magnolia House either in their own homes or in hospital. Once the full assessment has been completed and a decision made, the home now writes to the individual to confirm the outcome. Two people living in the home confirmed that someone had visited them before they moved into the home and that they had been given plenty of information about the home as well as visiting it themselves. Concerns have been raised by a healthcare professional, regarding a recent admission to the home. They felt that the home had inappropriately admitted this person. Information from the owner indicated that a full assessment had been undertaken, but that the individual had then become ill, necessitating a move from the home (see also Standard 16). The home does not provide intermediate care. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and give clear information to enable staff to meet resident’s health and social care needs. However, individuals, their representatives and health and social care professionals could be involved more in their formulation and decision making processes. Medication administration procedures are not always followed this has the potential to place residents at risk. The privacy and dignity of individuals living at the home is not always respected. EVIDENCE: Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 12 Everyone who lives at the home has an individual plan of care and some are in a new format that the home is just starting to use. Three of these plans were looked at, two in the new format and one in the old. The new format uses standard pre-printed forms and are very detailed. The old format is generally shows more information on goals and how they should be met. They each gave good information on what staff needed to do for individuals on a day-to-day basis. Staff that were spoken with said that they found the care plans very useful when changes had occurred to the needs of the individual. Staff showed a good knowledge of the individuals’ needs and preferences. Plans showed that they are generally kept up to date. However, one plan had not been reviewed for almost two years, and individuals and their representatives are not always involved in reviewing the plans. The owner indicated on the returned AQAA (Annual Quality Assurance Assessment) that this was one area that they felt they could do better. They intend to involve people who live at the home and their representatives more, in the drawing up and reviewing of care plans. There was evidence on file of regular visits from health care professionals and it was possible to see through recordings, where a health problem had been identified, healthcare professionals consulted and care given as directed. Risk assessments were seen for several areas of risk including, moving and handling, falls and the use of beds rails. Although the assessments for the use of bed rails were comprehensive, there was no evidence of multi-disciplinary involvement in the decision to use the rails. It is important to involve as many people as possible in making the decision to use bed rails, as they can be seen as a means of restraint. Medication is generally well managed and staff who administer medicines have recently received training from Boots who supply the medicines. The training looked at understanding prescriptions and MAR (Medication Administration Record) sheets, and knowledge was tested at the end of the training. Staff were able to describe good principles of administration. However, when medicines were looked at and MAR sheets checked, several items had not been signed for when given. Staff said that they had had to attend to another person in between giving the medicines and signing for them. There was generally a warm and friendly rapport between the people living and working at the home, and some very good interaction was witnessed. Staff were seen to offer personal care in a discreet manner. Several positive comments were received from people living at the home about the staff including ‘The care we receive here is of a high standard’ and ‘the staff are alright’. However, there were several situations witnessed during the inspection that raised serious concerns relating to the privacy and dignity of the people being cared for at the home. When we first arrived and were admitted through the front door, a bedroom door directly opposite, was open. An individual was sat Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 13 on a chair in full view of anyone coming to the front door, with no clothing to their bottom half. Another individual was wandering about the hallway in their night clothes, and several staff were heard to tell people to ‘just go and sit down’. The owner, manager and senior care assistant were very concerned, when told of these matters. They felt that it may have been due to the fact that they were one member of staff short that morning. These are major concerns that the owner agreed will be addressed. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are not always offered good choices in all aspects of daily living. Social activities could be improved. They do not generally provide daily variation and interest for individuals. Meals are nutritious and balanced and provide individuals with choice and variety. EVIDENCE: There are some activities on offer at the home and they try to provide some form of activity every day. Staff said that they had time most days to ensure an activity took place. One person said that there had recently been a visit from a gentleman playing a guitar and that they had exercises occasionally. However one person indicated on a survey form that ‘I have not been made aware of any activities I may take part in’. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 15 One resident had said that they would like to visit the Age Concern centre, however, when offered the chance to go, by a member of staff, they declined the offer. Most residents who were sat in the larger lounge felt that there was little for them to do during the day, though many residents said they enjoyed being in their own rooms listening to the radio or watching the television. The owner indicated on the returned AQAA that activities could be improved and more use could be made of the home’s mini bus. The AQAA also indicated that people from the local community and family and friends were always welcome, and this was supported by discussions with people who live at the home and their representatives. Residents are supported to maintain their religious beliefs by staff at the home and a record of individual wishes is kept in the care plans. There are no set routines as to the time that people get up and go bed. However, night staff start work at 8pm and day staff said that it was expected that anyone who needed help would be in bed before the night shift started. This practice means that people have no real choice over their bedtimes (see also Standard 27 Staffing). The home should ensure that careful attention is paid to ensuring everyone at the home has real choices concerning their lives. People living at the home said that their visitors were always made welcome and that they could come at any time. Relatives who were spoken with confirmed this, saying that they were always offered tea and biscuits as well. The menu that was seen is nutritious and quite varied. People said that ‘the food is lovely’, and that there was always something else if they wanted it. One person said that they were allergic to milk, but the home was so good she never noticed it was missing. The lunchtime meal has two sittings. Those that need help with eating have their meal first so that they may enjoy their meal and get the help they need without being rushed. Staff were seen helping people in a kind and sensitive way. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and simple complaints procedure that ensures complaints are responded to promptly with satisfactory outcomes. People are protected by staff who know their duty to report poor practice. EVIDENCE: There is a clear and simple complaints procedure that is available to people who live in, work at and visit the home. Staff said that they were able to deal with any little concerns by themselves, but would pass anything of a major nature onto the owner, who, they were confident would deal with the matter. Staff have recently received training in recognising and dealing with abuse. And the home has a whistle-blowing policy and procedures to follow in the event of concerns being raised. The staff that were spoken with were all able to describe differing types of abuse. They gave excellent answers in relation to the steps they would take in raising any concerns including alerting other people outside of the home. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 17 One concern has recently been received from a healthcare professional in relation to the admission process of the home. The owner supplied details of the admission and we are satisfied that the situation was dealt with appropriately. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides a homely environment, which is generally very clean. However, not all areas afford individuals’ privacy and are not always free form offensive odours. EVIDENCE: A full tour of the building was made and all areas seen were comfortable and homely looking, with furnishings and fittings in a domestic style. There are two lounges and a conservatory and two dining rooms for the use of those living at the home. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 19 In general the home was clean and fresh smelling, however when we arrived there was one area that was identified as having an offensive odour. This was discussed with the care manager who said that it may have been due to the time of day. The odour was gone when the area was re-visited. Individuals bedrooms are comfortable and there were many items of a personal nature around the rooms. However, some of the walls in some ensuite facilities do not go to the ceiling and one had only a shower curtain for a door. This does not ensure the privacy of the individuals using the facilities. Not all doors to individuals’ rooms are fitted with suitable locks. Some bedroom doors were seen wedged open. This was discussed with the owner who said that all upstairs doors had to be replaced, as they no longer meet fire requirements. Automatic closures will be fitted to the doors when they have been replaced. In the meantime they are encouraging people to keep their bedroom doors closed, and continually monitoring the situation. Restrictors have now been fitted to all windows where there may be a risk of injury from falling from them. Covers have been fitted to the remaining radiators where there was a risk that people may have been burned from the hot surface. Laundry facilities are suitable and good infection control measures are in place. Staff said that disposable gloves and aprons are freely available. Records show that staff have received recent training in infection control procedures. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers are not always appropriate to ensure that individuals are offered choices in all aspects of their lives. Staff are well trained in order to meet the needs of the individual. Arrangements for staff recruitment are good, ensuring that people are safeguarded from the risk of abuse. EVIDENCE: At the time we arrived at the home there were five care staff (we were told that this was one less than usual) and several ancillary staff on duty. The care manager arrived after approximately an hour and the owner arrived after lunch. Staff felt that though they did have some time to spend with individuals, there were many more times when they were very rushed and were unable to do much more than basic personal care. However, staff work hard to ensure that people do not have to wait for any help they may require. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 21 We were concerned to note that there are only 2 members of staff on duty from 8pm when the night shift starts. This limits not only the choice of bedtime but also the opportunities for social stimulation during the evening. This was discussed with the owner who has agreed to look at staffing rotas. Training records showed that comprehensive induction training is now being undertaken by new staff when they begin work at the home. Therefore peoples’ needs are now being met more consistently and safely. Staff said and records confirmed that they receive regular training, including moving and handling, fire procedures, dementia care, food hygiene and infection control. Staff who administer medication have recently received training in this area. However, even though staff have received regular training there is the potential for the dignity of people to be neglected because of staffing levels (see also Standard 10). The owner feels that staffing numbers are adequate, but that the general deployment of staff needs to be looked at. As stated above they will be looking at this. A total of 19 care staff are employed at the home, 10 of which have a qualification of at least NVQ (National Vocational Qualification) 2. Four others are working towards such a qualification. Four staff files were seen and three contained all the required information including, two written references, an application form, full employment history and a satisfactory CRB (Criminal Records Bureau) check. One file for an overseas worker contained only one written reference, but the owner is trying to obtain a second. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well managed resulting in practices that promote and safeguard the health, safety and welfare of people who live, work in and visit the home. Quality assurance processes do not ensure that the quality of care provided at the home is reviewed and improved. EVIDENCE: Mr and Mrs Keough have owned the home for many years and have much experience of caring for older people. The care manager is experienced and highly thought of by everyone at the home, has only recently returned from Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 23 maternity leave. Staff said that they felt well supported to do a good job and comments received on survey forms included ‘Lovely friendly home, the owners are really supportive, to residents and staff, and always there for everyone (nothing is too much trouble)’, and ‘Magnolia House is a clean and happy home for all. And we do get support from Mr and Mrs Keough if needed’. A series of questionnaires are sent out regularly to all interested parties. However, there is no evidence that the information collected from these surveys is used to identify or act upon any issues identified. There is now a formal staff supervision procedure, this ensures that staff are able to have a one to one meeting with their manager to discuss such things as training and development. The home does not manage any monies for anyone living at the home. Monthly accounts are sent out for any monies owed (newspapers etc) The pre-inspection questionnaire and AQAA (Annual Quality Assurance Assessment) provided evidence that Magnolia House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook and the record of fire safety training was generally well maintained, though it is kept in three separate folders and it is difficult to track events. However, there was no fire risk assessment for the home and fire extinguishers are not being visually checked each month. Accident records are completed well for all accidents. However, no audit is undertaken and therefore it is difficult to see if there is any pattern to accidents. For example, the records show that one individual had fallen 5 times in three months, but their risk assessment for falls had not been reviewed. There are risk assessments completed for all areas within the building and for equipment that is used. Magnolia House, Exmouth DS0000021974.V336140.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 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 2 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 25 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. Standard 1. OP10 OP23 Regulation 12 (4)(a) Requirement You must ensure that the privacy and dignity of individuals living at the home is maintained at all times. This relates to ensuring that appropriate clothing is worn at all times, suitable locks are fitted to bedroom doors and to the possible lack of privacy when using en-suite facilities You must ensure that there are arrangements in place to show that the quality of care provided at the home is reviewed and improved. You must make any such report available to everyone at the home as well as CSCI. Timescale for action 31/07/07 2. OP33 24 31/12/07 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 OP7 Good Practice Recommendations You should ensure that individuals and their DS0000021974.V336140.R01.S.doc Version 5.2 Page 26 Magnolia House, Exmouth 2. 3. 4. 5. 6. 7. 8. 9. 10. OP8 OP9 OP12 OP14 OP27 OP19 OP26 OP27 OP38 OP38 representatives have the opportunity to contribute to their care plan. You should ensure that as many people as possible are involved in deciding if bed rails are to be used. You should ensure that staff who administer medication follow the home’s procedures at all times. You should ensure that there are increased opportunities for people to participate in activities and outings of their choice. You should ensure that individuals have the opportunity to make real choices in all aspects of their lives. You should ensure that all bedroom doors meet the requirements of the fire authority. You should continue to ensure that all areas of the home remain free from offensive odours. You should ensure that there are sufficient numbers of staff on duty at all times to enable individuals to make real choices. You should ensure that a fire risk assessment is completed You should ensure that accident and incident reports are regularly reviewed. Magnolia House, Exmouth DS0000021974.V336140.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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