Inspection on 20/08/08 for Magnolia House, Exmouth

This inspection was carried out on 20th August 2008.

CSCI found this care home to be providing an Adequate service.

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 15/06/07

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 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Magnolia House, Exmouth 40 - 42 Morton Road Exmouth Devon EX8 1BA Lead Inspector Rachel Doyle Unannounced Inspection 20th August 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Magnolia House, Exmouth DS0000021974.V367165.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.V367165.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.V367165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2007 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 £381£490 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.V367165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over approximately six hours, one day at the end of August 2008. 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 people living at the home and staff. At the time of writing the report, responses had been received from 4 people living at the home (with assistance from staff), 2 staff and 5 relatives. Comments were generally positive. Some people living at the home have limited verbal communication and understanding skills, and as we are not skilled in their other methods of communication it was difficult for us to have any meaningful communication with these people. However, the interaction between the people living at the home and those who care for them was closely observed. During the inspection 5 people living at the home were spoken with individually and 5 in a group setting. People living and working at the home were also observed interacting throughout the day. We also spoke with 2 staff, the care manager and the owners. 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 generally good admissions and care planning procedures that assure individuals that their personal and healthcare needs could be met. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 6 There are good recruitment procedures and staff are well trained in knowing their duty to report bad practice. There is a clear and simple complaints procedure and the owner generally ensures safe Health and Safety practices. Pre-admission procedures ensure that the Home is clear that they can meet peoples’ needs before they move in. The owner submitted a full and detailed AQAA (Annual Quality Assurance Assessment) that showed a realistic assessment of the quality of the service provided. The Home works well with CSCI and have addressed, or are moving towards, improving the standard of care in relation to the requirements and recommendations from the previous inspection. What has improved since the last inspection? What they could do better: Though some 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. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 7 The Home needs to focus more on ensuring that they meet peoples’ mental health needs by enabling people to maintain their wellbeing through stimulation and meaningful activities that are appropriate to peoples’ capacity. Staff need training to enable them to meet peoples’ mental health needs fully including ensuring that information in the care plans is more detailed so that they know what to do to meet individual needs. 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.V367165.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.V367165.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, 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 so that they know that staff can meet peoples’ needs. Intermediate care is not provided at Magnolia House. EVIDENCE: Three pre-admission assessments were looked at on three peoples’ files, as part of case-tracking, and these covered a broad range of care needs, including skin care, social needs and continence issues. People living at the Home confirmed that either they had visited prior to moving to the Home or a relative on their behalf. The home does not provide intermediate care. The files of three people living in the home were inspected. All three people each had thorough pre-admission assessments completed prior to them Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 10 moving into the home. They contained comprehensive information that determined whether the home could meet the assessed needs of the individual. 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 writes to the individual to confirm the outcome. The Home provides welcome packs in peoples’ rooms including the previous CSCI report summary and the Home’s Statement of Person. The home does not provide intermediate care. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to ensure that residents and families are encouraged to participate in the plan of care and their reviews and to continue with regular reviews as required. Magnolia House, Exmouth DS0000021974.V367165.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, 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 generally give clear information to enable staff to meet peoples’ health and social care needs. However, information about peoples’ mental health needs is lacking which does not ensure that staff are able to meet these needs. The privacy and dignity of individuals living at the home is respected. There are robust procedures around medication to ensure the safety of people living at the Home. EVIDENCE: Four care plans were looked at, three as part of the case-tracking process. These are in a Standex format with clear front summaries. There is a good assessment looking at all the Activities of Daily Living. There was generally very good information relating to personal care such as ‘needs carer to style hair and make dressing choices’ ‘can choose if given simple options’ and ‘no Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 12 longer tolerates wearing her glasses’. The use of topical creams was well documented. There were some social objectives such as ‘can’t participate but likes to watch’. Risk assessments were completed relating to skin integrity and pressure area care, falls and nutritional needs and appropriate actions taken such as referral to a falls team at the hospital. All care plans were regularly reviewed and updated although changes were not always explained such as needing assistance from one carer to full bed bath and two carers. All care plans showed clear records when the multidisciplinary team visited and the District Nurses leave clear information for staff about any nursing issues. Staff were vigilant about any health changes and appropriate referrals were made such as to the audiologist. Personal care was very well managed with good continence promotion and ensuring people move position regularly. Relatives are involved in the care planning process and staff talk through the plans with people at the Home. Any use of restrictions is well managed involving the multidisciplinary team and relatives. Staff demonstrated a good understanding of peoples’ needs and were able to show good practice in relation to maintaining their privacy and dignity. They were discreet when asking people if they needed the toilet, for example. There was a lovely rapport between staff and people living at the Home who were heard to be given choices throughout the inspection such as where to sit or what to drink. All people living at the Home have a keyworker who looks at replacing toiletries etc. People spoken to were not able to engage fully with us but commented that ‘this is the best home round here’, ‘it’s nice isn’t it’ and ‘I’m happy’. However, all four care plans did not focus on mental health needs and how this affected peoples’ lives, for example why and how they needed assistance with personal care or maintaining independence. Any information was brief although there were some good social histories but no information about how this was used to maintain peoples’ wellbeing. Daily notes rarely mentioned how the person was other than in physical terms such as ‘awake all night’ but not how this was managed or supported. Another plan said that someone ‘remains in her room now’ with no clear reasons or ways to manage this other than ‘left in chair’ or ‘left in room’. The daily notes in another plan went on to say that another person was anxious today, probably from being in their room alone a lot. This was not followed up. One plan said that someone ‘shouted a lot’ with no explanation. Someone was said to have been aggressive but there were no further details of why or how to manage this. Some people were in their rooms and unable to use a call bell and there was no plan as to how to manage this to ensure that their needs are met. One person could not access a drink and staff did not visit this room for at least 2 hours. This was discussed with the care manager who will address this as a priority. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 13 Medication was well managed. All staff who administer medication have been trained. Storage, recording and disposal was satisfactory. No-one at the Home currently self-medicates although this is a possibility following assessment. People have also been assessed for holding their own door keys. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to improve training on Death, Dying and Bereavement and Mental Capacity Act training. Magnolia House, Exmouth DS0000021974.V367165.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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are offered good choices in all aspects of daily living. Links with visitors are promoted. The Home does not offer a suitable range of activities and stimulation to people at the Home to ensure their wellbeing or give opportunities to support and enrich peoples’ social lives. Meals are nutritious and balanced and provide individuals with choice and variety. EVIDENCE: We spent some time observing what people were doing all day. Although the Home have started to look at recording peoples’ activities and stimulation there was very little meaningful interaction with others for people living at the Home other than during tasks. When staff spoke to people there was a lovely, kind manner and obviously a good rapport but records in all four care plans showed that people had only had the radio on or sat in front of the television Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 15 for the last 6 months apart from some manicures and pedicures and an Easter Bonnet day. One staff member sat with someone for a couple of minutes, which the person obviously enjoyed but in the main, people sat in the lounge with the television on or in the other lounge listening to appropriate music, which was on all day. Some people were enjoying the music but this meant that the television could not be heard in the other lounge. When asked none of the people in this lounge knew what was on the television. Two people said ‘we don’t do anything, it’s boring isn’t it’ and another said ‘it’s a good question, what do we do now’. One person was obviously anxious in the lounge but this was not addressed by staff. However, some progress has been made and some people at the Home have been attending dramatherapy and chair exercise sessions. This has been successful. Information gathered by the facilitator about individuals could be used by staff and recorded in the care plans. There is a hairdresser who visits weekly, a chiropodist visits five weekly and the optician six monthly. It is noted that the Home are looking into improving the social aspect of care and are in the process of employing an Activities Co-Ordinator for 30 hours a week. Residents’ meetings are about to start. A programme has been drawn up for regular activities and outings. These have not been able to happen yet but are planned for the future and include visits to the theatre, garden centres for tea and cake and other outings. There was a lovely rapport between staff and people living at the Home who were heard to be given choices throughout the inspection such as where to sit or what to drink. Care plans record when people prefer to go to bed and other notes indicate that staff give thought to choice when carrying out personal care tasks. One relative commented that staff gave care with a lot of patience and understanding showing professionalism and compassion, which extends to the family. The Home have received many thank you cards from relatives. Another relative praised the Home’s pleasant and welcoming greetings. Most relatives’ responses mentioned that people living at the Home could have more opportunity to go out especially as the sea is only 100 yards away. We spent lunch-time with people living at the Home. This was very well presented in a lovely dining area with nicely laid tables and condiments. There are two dining rooms depending on peoples’ needs. Meals are individually plated up and staff knew what people liked. There was a choice of meal and desert. One carer spent a few minutes helping one person who said ‘I’ve got no-one to talk to’. Staff were attentive to peoples’ needs, promoting drinks. 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 AQAA (Annual Quality Assurance Assessment) submitted prior to the visit Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 16 indicates that in order to improve the service the home intends to employ an Activities Co-ordinator and continue to increase the range of activities and outings and to provide staff with therapeutic activity training. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 17 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, 18 Quality in this outcome area is adequate. 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 not always protected by staff who know how to report poor practice. EVIDENCE: There is a clear complaints procedure, which is included in the Home’s Statement of Purpose. Relatives who responded felt that they knew who to talk to if there was a problem and that they could talk to staff about any worries. Issues are then acted upon without delay with staff being helpful. Staff were not always clear as to the procedures for reporting safeguarding issues. All staff have undertaken Protection of Vulnerable Adults training but the Alerters’ Guide could not be found and there is no specific Safeguarding policy. Staff were not aware of Care Direct or the telephone numbers to make an alert. The care manager said that they would look into this to ensure that people are safe. One care plan noted bruises on someone’s skin but this was not clearly Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 18 explained or recorded so that it could be monitored. This person was known to have delicate skin. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to ensure the continuation of training (In-House), update policies and procedures as required and display any publications in the staff area. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 19 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, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides people living there with a clean, safe, comfortable and homely place to live. 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. The Home was clean and fresh smelling in all areas. Individuals’ bedrooms are comfortable and there were many items of a personal nature around the rooms. Although some of the walls in some ensuite facilities do not go to the ceiling there are shower curtains used for Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 20 privacy and staff were seen to manage this well and the main bedroom doors were kept shut during personal care with staff knocking on doors. Automatic closures have been fitted to all fire doors to allow people to open doors safely. One bathroom does not have a lock and this should be addressed. Restrictors have almost been fitted to all windows where there may be a risk of injury from falling from them. The Home will risk assess those that are remaining. Covers have been fitted to radiators where there was a risk that people could be burned from the hot surface. Hand washing facilities are available in the laundry area. Liquid soap, gloves and paper towels were seen in residents’ rooms to help prevent cross infection. Laundry facilities are suitable and good infection control measures are in place. Three of the nine staff have had specific training. Staff said that disposable gloves and aprons are freely available and were seen using them appropriately. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue with on-going maintenance and make further improvement to the front garden area with tables, flower pots and hanging baskets to make it visually attractive. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the Home benefit from friendly staff in appropriate numbers who are able to meet the needs of the individual, although training in dementia care would ensure that staff are better equipped to meet mental health needs . Arrangements for staff recruitment are good, ensuring that people are safeguarded from the risk of abuse. EVIDENCE: At the time of the inspection there were 18 people living at the Home. Staff levels are based on dependency levels and changed accordingly. There were 4 carers including the care manager on duty and a further carer arrived so that the care manager could be available during the inspection. There are usually 6 carers in the mornings when the Home is full. Staff generally felt that there were enough staff to meet peoples’ needs. When peoples’ needs were higher the Home had another carer in the evenings. There are 2 waking night staff on duty. The care manager confirmed that night staff only assist people to get up if people choose to. The Home has their own trainer who is a lecturer and National Vocational Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 22 Qualifications Assessor. They are available three days a week and support staff taking NVQ. All mandatory staff training was up to date. Training records were looked at and staff have undertaken a range of training such as Emergency First Aid and Food Hygiene. Few staff have had any recent training related to the Home’s category, which does not ensure that staff are well equipped to meet specific needs. Three staff files were looked at and all contained the required documentation to ensure that there is a robust recruitment procedure that protects people at the Home. Relatives’ comments about staff were very positive. These included: ‘staff are competent, enthusiastic and caring in a good atmosphere and pleasant surroundings’, ‘staff always make people living at the Home feel loved and treat them with great kindness and feeling’ and ‘staff are happy in their delivery of care’. Staff spoken to said that they enjoyed working at the Home, some having been there for some time and know the people living at the Home well. All staff were very helpful during the inspection. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue with the constant process of updating training, commence In-house training and to support all staff undertaking National Vocational Qualifications, providing them with learning opportunities and allocated work time. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35, 38 Quality in this outcome area is good. 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 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. Arrangements have been made to Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 24 ensure that the Home is well managed while she is on maternity leave. Staff spoke highly of the management and are well supported to do a good job. The Home now have an excellent quality assurance system to enable them to regularly review and assess the standard of care. A series of questionnaires are sent out annually to all interested parties, recently sent in February. There is a pie-chart feedback form and actions are taken that are appropriate to comments received. Questionnaires can be sent anonymously and surveys also go to relatives The home does not manage any monies for anyone living at the home. Monthly accounts and reminders 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, including fire risk assessments and checks. There was an excellent analysis of any falls with good action plans. Policies were easy to read covering a wide range. Staff sign when they have read them but the system could be improved to ensure that all staff have read all policies. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. 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. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue with staff training, ensure regular accident audits and review and regular reviews of risk assessment for all areas of the building. Also to continue to support staff fully with NVQ and training issues and implement a Health and Safety consultants package. Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 25 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 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 20/10/08 2. OP12 16 (m) (n) 3. OP18 13 (6) 4. OP30 18 (1) (c) You must ensure that care plans show clear information about how to meet peoples’ mental health needs so that these an be met. You must ensure that you 20/10/08 consult people and/or their representatives about their social interests and make arrangements to enable them to engage in local, social and community activities and provide facilities for recreation. You must ensure that 20/09/08 arrangements are made to prevent people living at the Home from being harmed or being placed at risk of harm or abuse. You must ensure that persons 20/12/08 employed to work at the Home receive training appropriate to the work they are to perform. This refers to specific training related to the Homes’ category and peoples’ needs. Magnolia House, Exmouth DS0000021974.V367165.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. Refer to Standard OP8 Good Practice Recommendations You should ensure that peoples’ mental health care needs are identified and met. This includes managing those people who spend most of the time in their rooms and are unable to access their call bells. You should ensure that there are increased opportunities for people to participate in outings of their choice outside the Home. You should ensure that all bathrooms have appropriate locks to promote privacy. 2. 3. OP12 OP19 Magnolia House, Exmouth DS0000021974.V367165.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Magnolia House, Exmouth DS0000021974.V367165.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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