Inspection on 12/06/07 for Mallands Care Home

This inspection was carried out on 12th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mallands Care Home 08/03/09

Mallands Care Home 09/01/08

Mallands Care Home 22/08/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Mallands Care Home Odle Hill Abbotskerswell Newton Abbot Devon TQ12 5NL Lead Inspector Margaret Crowley Unannounced Inspection 12th June 2007 07:00 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 Mallands Care Home DS0000067260.V337945.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. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mallands Care Home Address Odle Hill Abbotskerswell Newton Abbot Devon TQ12 5NL 01626 366244 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) Mallands Care Ltd vacancy Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38), of places Physical disability over 65 years of age (38) Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 38 service users aged over 65 years may be accommodated in the category of Old Age A maximum of 38 service users aged over 65 years may be accommodated in the category of Physical disability (PD(E)) A maximum of 38 service users aged over 65 years may be accommodated in the category of Dementia (DE(E)) 22nd August 2006 Date of last inspection Brief Description of the Service: Mallands is registered to provide care for 38 older people who may also have a physical disability and/or dementia. It is a large detached older property with a purpose built extension and provides accommodation on the ground and first floors. The ground floor has spacious communal rooms including 2 lounges, one of which overlooks the garden and a dining room. All bedrooms have en suite facilities or an adjacent toilet. There are two passenger lifts for people who are unable to use the stairs. The home provides aids and adaptations to meet people’s needs including grab rails, mobile hoists, adapted baths and a walk-in shower room. At the front of the house there is level access to a pleasant garden and seating areas. Since the last inspection the property has been extended to provide seven additional bedrooms, an adapted bathroom, and additional office space on the second floor. Mallands is located on the outskirts of the village of Abbotskerswell, Newton Abbot. There are local shops, a church and a public house within the village and a wide range of amenities in Newton Abbot. Fees currently range from£375 Written information is provided for people considering going to live at Mallands and those who are resident. A copy of the most recent CSCI inspection report is available. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 14 hours on 12th and 13th June 2007 by Margaret Crowley regulation inspector, who was accompanied by Clare Medlock regulation inspector on 12th June. Mr Leadbetter, the responsible individual for Mallands Care Ltd, was available for part of the inspection on each day. Assistance was provided from the two administrators and the two assistant managers who were managing the care services. There was no registered manager available because Miss Sally Gribble, the former registered manager, resigned in May 2007. She had not been working in the home for two months. At the time of the inspection interviews were in progress to recruit a replacement manager. There were 34 people resident in the home during the inspection and 2 people receiving day care. Many were spoken with, including 8 in more depth regarding the lifestyle in the home and the care services they receive. A tour of the premises was made. Records were inspected, including care, medication and staff records. Staff were observed and spoken to in the course of their daily duties. Feedback questionnaires were received from 8 people who live at the home, 7 relatives and 4 staff. Feedback was also received from 3 general practitioners and the district nursing service. What the service does well: What has improved since the last inspection? Improved systems are in place to identify any concerns about people’s health, including pressure sores, and to refer them for medical treatment. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 6 Staff have received training in meeting the special needs of people with dementia and in moving and handling people safely. Systems to record the administration of medication are safer and include information for staff regarding why medicines are used. However, staff have not yet received further training in administering medicines. Early morning routines have improved and breakfast is now served with a more flexible timescale. The premises have been extended and upgraded, to provide seven additional bedrooms with en suite facilities, and an adapted bathroom. Signage within the building, including names on bedroom doors, has improved. This assists people who are new, and those with dementia, to find their way around the premises. Paper towels have been installed in communal toilets to prevent the spread of infection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 7 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 Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 8 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): Standards 2,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive information to assist them in choosing to live at Mallands, but there is limited assessment information to assist staff in providing care for new residents. EVIDENCE: Two people who had been admitted to Mallands recently were spoken with. One was receiving respite care following her discharge from hospital. She was very pleased with the care that she was receiving and said staff had been welcoming at the time of her arrival. The second person had been at Mallands for only a few days. This person was unsure of the routines in the home and whether staff at the home would be able to meet her needs. Records were inspected of three new people. They had been visited in hospital by senior staff and a pre-admission assessment undertaken. The form used to Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 9 record the assessment does not show that it is done before coming to the home. Those seen were not completed in detail, dated or signed by either the person completing the form, or prospective resident. The records did not provide a comprehensive assessment of the person’s needs. The records inspected contained a two- sided form entitled “Care Plan”. This brief document is both a factual admission sheet and a care plan. They were not fully completed and did not contain important information such as the date of admission, or give sufficient advice to staff in providing care for the new person. Completed contracts, or statements of terms and conditions, all stated the room to be occupied. A letter had been sent to people wishing to live at Mallands advising them that home was able to meet their assessed needs. These are matters addressed since previous inspections. Mallands does not provide intermediate care. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 10 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): Standards 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. Although some action has commenced to address inadequate care planning and record keeping processes, this is not yet sufficient to ensure that people living in the home receive consistent care. EVIDENCE: Comments made by people living in the home and their relatives were generally positive regarding the care services they receive. Although some people said that staff were “busy”, it was also said “ when I need someone they come quickly”. All relatives who replied to questionnaires commented on the staff’s caring approach. Positive feedback was also received from 3 general practitioners regarding the service the home provides. The inspectors observed staff speaking to people who live in the home in an appropriate and friendly manner, and being considerate when they were assisting them within the home and at mealtimes. Two relatives raised concerns about residents’ appearance and clothing, but during the inspection people looked well presented and their clothing well laundered. However, one person who was in bed was observed to have dirty fingernails. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 11 The inspectors examined a sample of care records, and communication processes and systems within the home. This was to assess compliance with Statutory Requirement Notices issued by CSCI on 4th May 2007, regarding pressure area care and the need for each resident to have a complete plan of care based on a comprehensive assessment of his or her needs. The notices were issued followed a serious complaint regarding the lack of attention to a former resident’s health and personal care needs, including the care, prevention and treatment of pressure areas. Following a Safeguarding Adults meeting, the district nursing service had carried out specialist assessment reviews of all residents in April 2007. They identified further health care concerns that had not been identified and recorded in the care records and referred for treatment. They also found that care staff had a lack of awareness and training in first aid practices and manual handling. The inspectors saw some improvements in place to address health care issues. A new “concerns log” has been introduced in which staff record any health care concerns about residents and the action taken. This is to enable concerns such as pressure areas to be identified and referred for specialist treatment. Pressure relieving equipment was in use for a person who had a pressure sore. This plan of care and use of equipment had not been recorded in the care plan, but was recorded after the initial day of inspection. In-house training in pressure area care was being provided for care staff by one of the assistant managers.Training has also been arranged from an external trainer with specialist knowledge. A new information folder regarding pressure area care was available for care staff. A new process has been introduced to monitor the fluid and nutritional intake of any person where this is a concern. Feedback from the district nursing service indicated that there has been progress in the manner in which staff at Mallands were addressing the healthcare needs of people living in the home. District nurses are now receiving referrals in a timely manner and have improved access to care plans. The Commission continues to have concerns regarding the detail and timely way records and care plans are written and co-ordinated at the home. There was evidence that work had commenced to provide each person with a file containing an updated plan of care, which includes a monthly review. However, this had only been achieved for 2 of the 34 people living in the home, within the required time scale. There was no evidence that the person concerned or their relative had been involved in the review. Feedback comments were received from a relative who would like to be involved in reviews. Many care plans were still out of date and people’s care needs and risk assessments had not been updated. Despite requirements made at two previous inspections, daily records and communication systems still lack adequate co-ordination, which continue to be compounded by the manual and computerised recording systems. In the absence of a registered manager, the assistant managers are the only staff responsible for co-ordinating information and inputting on computer daily records, care plans and reviews. This places additional pressure on their time. Care staff, including night duty staff, do not have access to the computer Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 12 records where most information is held. These staff pass on information to senior staff, who then record the information on computer records. This means that information could be missed or forgotten if the assistant managers are sidetracked, as was seen during the inspection. Records are only printed off and placed in the care files periodically, so that current records are not available at all times for staff providing care and visiting professionals. The responsible individual for Mallands Care Ltd said that the failure to comply with the Statutory Requirement Notice was due partly to the ill health and subsequent resignation of the registered manager. The Commission agreed to his request for an extension of 3 months in which to complete the process. Medicines were observed to be administered appropriately. Medication administration records were generally well maintained. New entries on the MAR (Medicine administration record) sheet were handwritten. Improvements were suggested to ensure errors are minimised when prescriptions are copied onto these records. Improved information has been provided on the MAR sheet for staff regarding why medicines are used. A record is now kept of the application of creams. Some creams did not show the date of opening, and lids were not always secured. Mr Leadbetter said that they were awaiting confirmation of a date for further training for staff in the administration of medicines. Comments were received from a general practitioner who carries out twice yearly medication reviews in the home that medication appears to be used appropriately. The assistant manager stated that she usually checks the medicine cupboard on a monthly basis for expired products, but this has been delayed in recent months because of her additional workload. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 13 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): Standards12,13,14,15. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The planned activities provide interest for people living in the home, but people’s preferences regarding daily routines are not always sought and recorded. EVIDENCE: A programme of activities is provided which includes games such as bingo, scrabble, and trips out. Themed events, chosen by the more able people take place both indoors and in the garden when weather permits. A Hawaiian party was being planned at the time of the inspection. Daily activities are displayed in reception and recorded in an activities book. This includes chiropody and hairdressing. One relative valued being invited to events and meals, while another commented, “ it sometimes seems a little regimented in what they offer”. Staff were observed to have little time to spend speaking individually with residents. One person said “it would be nice if someone came to have a cup of tea with me”. The home has made some efforts to address institutionalised processes. Following a complaint received by the Commission, a more flexible approach to breakfast and getting up routines has been introduced. Most people are now given a cup of tea at 6am and begin to get up from 6.15am. Breakfast is served from 6.30am until 9.30am. At 7 am on the morning of the inspection Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 14 there were 4 people in dining room having breakfast, who were joined by 4 others by 7.30am. These people did not all have dementia and some said they like to get up early. However, care plans examined did not show that the person or their relative had been consulted regarding their choice of daily routines and their preferences regarding times of getting up and going to bed was not recorded. During the inspection a small number of people had breakfast in their rooms, but there was a lack of flexibility regarding the time that this is provided. The inspector was told that breakfast trays are not served until 8.30am. People said that the food was very good and that alternatives to the menu are always available. Special diets are catered for and recorded in the kitchen. The meals seen during the inspection looked appetising and were of a good standard. One resident said that drinks are not served hot enough. Relatives and visitors said that they are made welcome at all times. Some people living in the home said they enjoy continuing to visit family and friends locally. Mallands enjoys good links with the village of Abbotskerswell. A small number of older people currently visit Mallands for day care. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to address concerns and complaints, but a lack of awareness of processes to safe guard adults could place people at risk. EVIDENCE: The home has a written complaints procedure, which is contained in the service users’ guide and on display. Feedback questionnaires from people living in the home and comments made indicated that they were aware of how to complain or would raise concerns via a relative, should the occasion arise. The complaints book showed that 8 complaints had been recorded since the last key inspection, six were from residents or relatives, and two from staff. All had been investigated, although the complaints book does not indicate formally whether the complaint was upheld or not. CSCI has received two complaints since the last inspection. One complaint was regarding early morning routines and referred to in the previous section. The second was regarding the care of a resident and is referred to in the section regarding health and personal care. Both complaints were upheld and referred to the safeguarding adults process. The home has an adult protection policy and procedure. Some staff have received training in the protection of vulnerable adults. Further training for staff was recommended at the recent safeguarding adults meeting to raise awareness of protection issues. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 16 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): Standards 19,26.Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People live in an attractive, comfortable and well maintained home. EVIDENCE: Mallands is decorated in a homely style and has pleasant communal areas and attractive level gardens for people to enjoy. The home has its own maintenance worker and routine maintenance work is attended to systematically. A tour of the premises took place and all bedrooms were seen. They were found to be well decorated, clean, comfortable and personalised to the person’s individual taste. Relatives and people living in the home commented on the pleasant surroundings and the quality of the accommodation The premises have been extended and upgraded since the last key inspection to provide seven additional bedrooms with en suite facilities, and an adapted bathroom. Additional office accommodation has been provided, which will Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 17 enable the registered manager to have a designated office for confidential discussions with people living at the home, staff and visitors. Signage within the building has been improved to assist people’s orientation. New name plates have been fitted to bedroom doors, and symbols used where appropriate The premises were generally clean, hygienic and free from unpleasant odours, other than from the two toilets adjacent to the lounges and the dining room. One relative also commented on this. The management said that these toilets are cleaned periodically throughout the day, because of the high volume of usage. On the morning of the inspection three domestics were rostered to be on duty, but unfortunately only two were present because one was sick. Paper towels have been installed in communal toilets to prevent the spread of infection, as recommended at the last inspection. Fewer wheelchairs were seen stored on the premises than at the last inspection, but some were still stored in bedrooms of limited size, which reduces the accessible space for the person occupying the room. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 18 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): Standards27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on duty does not ensure that there are always sufficient skilled and experienced staff available to meet people’s needs in a safe and unhurried manner. EVIDENCE: Communication seen between staff and people living in the home during the inspection was friendly, caring and courteous. People said that staff were kind and helpful, and relatives confirmed this. However, 3 relatives commented on the need for more training and experience for the younger staff and the need to employ more mature and experienced staff. Several people said that staff “were busy” and this was seen when they were waiting for assistance to get up and for a cup of tea. The inspector observed that there was little visible presence of staff in the lounge for approximately an hour during the morning, and staff were very apologetic that morning coffee was half an hour late. Staff rotas were inspected, but an examination of the staffing complement on previous days showed that these staffing levels were not always maintained. Since concerns were raised regarding staffing levels at previous inspections, the number of staff has been increased by one full-time equivalent post. This is split between early morning and evenings because of the lack of safe staffing levels at those times. There has been no increase in staff numbers to take account of the increase in occupancy levels since the home was extended. The home continues to provide a day care service for between 2-4 people, which also includes the opportunity for them to have a bath. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 19 On the days of the inspection there were 34 people living at Mallands and 2 people present who receive day care. The responsible individual said that the staffing levels were sufficient to cater for the needs and numbers of people currently living in the home. He said that the home is seeking to recruit more staff and that shortages occurred when staff went sick or took unexpected leave. Agency staff are not employed to cover vacant posts or emergencies. There have been several changes of staff since the key inspection in August 2006, including all six of the former experienced night care staff. The current staff group lacks a good mix of skills, training and experience. None of the 18 care assistants hold the National Vocational Qualification in Care at level 2 or above. Only the two assistant managers have the qualification. There was no evidence of a systematic process to identify and address staff’s individual training needs, including mandatory training in safe working practices and first aid. No induction records were available for staff recently employed. The home lacks a training strategy and there was no visible staff training programme available to show training booked and planned. In addition there was no evidence that staff have received regular supervision, which is recorded. Staff have recently received moving and handling training, and training in caring for people with dementia, which were requirements at the last inspection. The inspector has been informed since the inspection that training in pressure area care from a trainer with specialist knowledge and skills has now been arranged. There are clear recruitment procedures, and staff records inspected showed that references and Criminal Records Bureau disclosures and Protection of Vulnerable Adults checks are undertaken to protect people living in the home from potential abuse. The staff application form does not ask the applicant to state the reason for leaving previous employment, nor does it contain a declaration of health. The administrator was advised to revise the form to include these. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 20 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): Standards 31.33,35,38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Mallands lacks a skilled competent manager to manage the provision of care and to ensure the health and welfare of people who live in the home. EVIDENCE: There is currently no registered manager. The former registered manager, resigned in May 2007 and at the time of the inspection there had been no registered manager working within the home for two months. Interviews were in progress at the time of the inspection and the responsible individual was optimistic that a new manager would be in post by August. The Commission has not yet been informed that a manager has been appointed. No temporary manager has been appointed in the absence of a manager . In the interim the management of care has been provided by two assistant managers, one of whom had only been in post for 1 month and had no previous experience of management in a care home. The inspectors observed Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 21 that their time was extremely pressured. In addition to overseeing care practice they were carrying out improvements to comply with the 2 Statutory Requirement Notices referred to previously, regarding pressure area care and care planning. No additional care staff had been appointed to ease their workload. The assistant manager was seen to be continually interrupted from her daily tasks. This could mean that information is missed or not communicated effectively. Although Mallands Care Ltd employs administrators to manage administrative matters in the home, they are not involved in the management of care practice. The views of people living in the home and their relatives are sought via quality surveys that are undertaken regularly. There is minimal involvement with people’s finances, as either the person or more usually a relative or a representative manages this. Evidence was seen that payments made by the administrator on behalf of a person are invoiced monthly to the individual or relative. Routine health and safety maintenance processes are managed satisfactorily. Evidence was seen of regular checks and tests completed in respect of fire safety, electrical, gas water systems and lifts and hoists. The fire risk assessment had not been reviewed recently to comply with the Regulatory Reform (Fire Safety) Order 2005. The management is advised to obtain a copy of the HM Govt Fire Safety Risk Assessment Guide. Accident records were inspected. These are recorded on accident report sheets. In discussion, it was suggested that a format is used which allows better cross-referencing. Accidents are also inputted on the computerised records and included in the person’s case records. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 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 2 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 3 x 3 x x 2 Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes 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 OP3 Regulation 14 Requirement Timescale for action 12/09/07 2. OP7 3. OP9 Prospective residents must have a comprehensive assessment of their care needs, which is recorded, to ensure the care staff are aware and have planned for their needs prior to their admission to the home. 12/09/07 15(2)(b)(c 1.Each resident must have a )(d plan of care based on a comprehensive assessment of his or her needs, which is reviewed at least once a month and updated to reflect their changing needs. 2.The resident and /or his or her representative should be involved in the review of the plan of care, particularly when the resident’s needs change. Previous timescale of 11/06/07 not met. 13(2) Staff administering medicines 12/09/07 must be assessed as competent and have basic knowledge of how medicines are used and to recognise problems in their use. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 24 4 5. OP18 OP37 13(6) Staff must receive training in safeguarding adults. 17(1)Sche Residents’ records must be codule 3 ordinated and accessible at all times to staff providing care and for inspection. They must provide information as required in Schedule 3 of the Care Homes Regulations 2001.Previous timescales of 22/01/07 and 12/06/07 not met. The number of staff on duty must be reviewed to ensure that there is always sufficient skilled and experienced staff available to meet people’s needs in a safe and unhurried manner. A staff training plan must be produced to show training planned and undertaken by all staff. 12/11/07 12/09/07 6 OP27 18(1)(a) 12/09/07 7 OP30 18(1)(c) 12/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3. Refer to Standard OP29 Good Practice Recommendations The application for employment should ask the applicant to state the reason for leaving previous employment, and contain a declaration of health. Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Mallands Care Home DS0000067260.V337945.R01.S.doc Version 5.2 Page 26 - 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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