Inspection on 19/06/06 for Malvern House

This inspection was carried out on 19th June 2006.

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

Malvern House 30/11/09

Malvern House 26/11/07

Malvern House 29/06/07

Malvern House 20/03/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Malvern House 271-275 Hale End Road Woodford Green Essex IG8 9NB Lead Inspector Zita McCarry Key Unannounced Inspection 19th June 2006 06:10 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 Malvern House DS0000067137.V298078.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. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Malvern House Address 271-275 Hale End Road Woodford Green Essex IG8 9NB 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) 020 8531 5081 020 8531 5084 Malvern House Retirement Homes Ltd Ms Jacqueline Broom Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34) of places Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total beds to be used flexibly between categories (34). Date of last inspection Brief Description of the Service: Malvern House is a privately owned care home offering residential accommodation and support to 34 elderly people, including those with dementia. There are 2 double bedrooms and 30 singles. All have wash hand basins and several have ensuite toilets. There are two lifts and access is suitable for those with limited mobility. There are three bathrooms, with assisted baths. There is a conservatory, patio and attractive garden planted to lawn and flowers. The home is situated on a main road in a residential area of Chingford (in the London Borough of Waltham Forest) with access to local shops and transport links. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of an unannounced inspection, undertaken by two inspectors in early June 2006. The inspection involved a tour of the premises and speaking with service users and staff. The inspectors examined a variety of records pertaining to the running of the home the care of service users and the management of staff. The inspection commenced at 6.10am in response to an anonymous complaint received that service users were assisted out of bed in the very early hours of the morning. The complaint was upheld. The inspector read feedback form relatives of service users that was very positive about the service. However as is documented in this report the inspection revealed a struggling service with inadequate staffing levels, who do not have adequate training or support. What the service does well: What has improved since the last inspection? What they could do better: The home has a considerable amount of work to improve the quality of life experienced by service users. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 6 The home will need to undertake comprehensive assessments before admitting service users so that they are not admitted to a service that does not fully understand what their care needs are. When admitted their plans of care will have to be sufficiently detailed to describe the service to be provided. The home will have to ensure all accidents and incidents are recorded and responded to adequately and keep the Commission informed of any occurrences affecting the wellbeing of the service users. The home will have to improve how it maintains service users’ confidentiality in the storage and handling of information. The service has been required to address the issues of safety such as corrosive chemicals left in an areas accessible to service users and electrical cabinets open. To put these improvements in place the home will need to provide further training for staff, improve staffing levels and introduce systems that enable service users and staff to affect the way the service is managed. 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. Malvern House DS0000067137.V298078.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 Malvern House DS0000067137.V298078.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home admits service users without taking sufficient measures to identify the prospective service users needs and history. EVIDENCE: To check the homes pre admission assessment process the inspector reviewed the file of the most recently admitted service user. The service had used a year old social work assessment. The assessment referred to an occupational therapy assessment but there was none available in the home. The staff from the home had undertaken an assessment but this failed to reflect the service users situation at the time of referral. There was a doctors report detailing a several medical conditions that would impact on the service users functioning, however none of this was referred to in the homes preadmission assessment and so the home was unable to demonstrate it had sufficiently considered its ability to meet the service users needs prior to admission. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 9 The lack of information obtained at a pre-admission assessment was evidence when the inspector noted from a communication that another service user was admitted into a room “that is totally unsuitable for X and 2 carers, X is left handed and all the room is arranged for a right handed person”. Staff confirmed that the service user was later transferred to a larger room. However had the assessment been adequate then the service user would never have been admitted to an inappropriate room. Malvern House DS0000067137.V298078.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service does not ensure service users prompt access to health services. EVIDENCE: The inspector reviewed two service users care plans. It was evident that the staff in the home had worked hard at introducing care planning to the service however more work must be undertaken to have a effective system that details how the service is to be provided to each service user. The inspector was pleased to note that the home had introduced a strengths assessment this are highly valuable tools in providing in the promoting wellbeing for people with dementia. Regrettably having identified service users strengths the home has not built these into a careplan that addresses every area of need as detailed in standard 3 of the National Minimum Standards. A care plan needs to detail the actions required of staff to meet the identified need and service users identified strengths should be reflected in this. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 11 Care plans are not yet in place to describe how staff provide care for service users, this is of concern particularly in light of some risks identified for service users. On one risk assessment it was noted that a service user had a high risk of visual hallucinations, but there was no care plan detailing an appropriate response from staff, which would be crucial for the wellbeing of the service user. Similarly risks of falls were identified with an outcome of “close monitoring”, again there is no detail on the level of supervision staff are to provide, or if there are times or areas where the service user is more likely to fall. The management of information in the home is inadequate. Staff have a complaints book, a handover book and a communication book and throughout these there are a variety of reports and information on service users. Reports that when tracked are not recorded in the service users daily records within their personal file. These books are stored on a table in the service users dining room thus sensitive and confidential information is available for anyone to read. Staff were observed to be entering service users bedrooms without knocking and waiting for permission to enter. There was an entry that noted a service user was threatening self harm, yet in the daily reports this was not recorded and no details that appropriate medical attention was sought and the outcome of that, no directions to monitor and no evidence of monitoring. In the staff handover book there was directions to staff to lay a mattress on the floor to cushion a service users fall. Again this was not appropriately recorded in the daily records. The inspector was also very concerned about these directions if the service user was to attempt to get out of bed the mattress would grossly undermine her safety. It was also unclear why these directions would be given as the risk assessment reflected measures already in place to address this risk. The home holds an employee accident at work book and in this records accidents to service users. The format does not provide sufficient detail for staff to detail all action taken, and follow-ups. The inspector found evidence that the home does not consistently record service users accidents in the accident record book so it is therefore difficult to judge the actual number of accidents in the service. There were records of several serious occurrences that affected the health and wellbeing of service users that the Commission had not been notified about as is required of a registered service. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 12 The inspector observed of staff using equipment not safe for its purpose. Staff were transferring service users in wheelchairs without footplates, this puts service users at risk of getting their foot caught under the wheelchair which can result in very serious injuries. The inspector pointed this dangerous practice to the manager but later in the day staff were observed to continue with the practice. The inspector asked the registered manager about the occurrences of pressure sores and was advised no service user had pressure sores. This was misleading as the inspectors found evidence that that 5 service users had pressure sores. The inspector tracked the treatment of one service user with a pressure sore and could find no evidence that she had been referred to the district nurse. The district nurses notes did not record that the service user had been seen, similarly the homes own records noted that the service user had been last seen bay a district nurse four months earlier. On a tracking the treatment of a second service users there was over a weeks delay in the recording of pressure sore symptoms and the district nurse visiting the service user. The service has introduced a new system for managing service users medication and there has been a dramatic improvement in the handling of service users medication. The day of the inspection fell on the day the new medications were received. The inspector checked the previous months medication administration records against a random sample of returned medications. Malvern House DS0000067137.V298078.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service fails to provide service users with adequate support to meet their daily needs. EVIDENCE: It was positively noted that the service has appointed an activity co-ordinator who knows the service users. At the time of the inspection the service users lounges were decorated with bunting made by them to mark the World Cup Football tournament. However the home had not obtained sufficient information on service users social and leisure preferences and there is no advertised schedule of what is to take place. Staff report service users are offered painting, bingo, dominoes, darts and manicures. However there was evidence that service users were unable to take part in the activities offered and there was nothing more appropriate offered to them. As a service providing care for people with dementia it would be expected that there would be activities adapted to meet their disabilities. The service has no restriction on visiting and service users see visitors in the lounge or the privacy of their bedroom. The inspectors found several examples where service users did not exercise choice and control over their lives. There are insufficient dining tables to Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 14 enable service users to choose where to eat, the inspectors observed a high number of service users having their meals served in the lounge on trays. In the interests of maintaining service users mobility, prevention of pressure sores and promoting social interaction service users should be supported to eat their meals at a dining table. When the inspector arrived in the service at 6.10am he found 8 service users up and dressed in the lounge and most asleep. The manager stated that this is the service users choice and most social files record this very early rising as the service users preference. However it was unclear how it was ascertained that the service users like to rise at 5am , 5.30 am and 6am. From and entry in the staff handover book a message was left to the night staff suggesting that staff may be deciding service users time of rising in relation to two service users. The entry stated “X must get up in the morning …….Y must get up as well”. The inspector observed tea being served to the service users by a member of staff, the inspector was concerned to note that the drink was poured from the teapot with the milk already mixed the member of staff advised the inspector that “it was easier to do it that way”. A record of the home’s menu evidenced that service users were offered a choice of foods. However the inspector met with a service user whilst she was eating lunch she had eaten only her vegetables, when asked if she enjoyed her lunch the service user responded “well I don’t eat fish I don’t like it” the service user had been served steamed fish in a cheese sauce. Another service user reported the food was “often cold when it arrives”. The service user meals come from the kitchen already plated so further opportunities to ensure choice is lost. The inspector noted one service user trying in vain to feed herself as she was almost lying on a reclining chair, most of her lunch had fallen on top of her as she tried to negotiate the very awkward process of balancing food on a fork from a small low table the height of her knees all the way up to her. When the inspector raised this with staff she was told “X always slides down the chair” if this is the case then staff must be vigilant and ensure the service user is sufficiently supported. It was of concern particularly in a service for people with dementia to note that not only did the meals come already plated but both the main meal and the dessert was served to the service users on the tray at the same time. This practice adds to the confusion of service users and does little to enhance their wellbeing and again fails to evidence any choice. Malvern House DS0000067137.V298078.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service fails to demonstrate adequate response to concerns about care. EVIDENCE: The home has a complaints procedure although this print in this needs to be enlarged and placed in prominent areas around the home for service users and relatives to access. The home has a complaints book for staff and one for service users, there had been no complaints recorded in the log for service users. Pages had been removed from the staff complaints book however the inspector found information where staff had complained about a lack of care for a service user. Unfortunately this was not formally recorded as a complaint or adequate response given. The Commission received an anonymous complaint regarding service users rising times and that staff under instructions were getting service users up exceedingly early. As documented earlier in this report 8 service users were up washed and dressed and most fast asleep in armchairs at 6.10 am when the inspector arrived. Care files recorded service users preferred time of rising from as early as 5am. The Commission upholds the complaint made anonymously. The home has had an adult protection investigation, which has now been satisfactorily resolved. Not all staff have had adult protection training. The inspector had the opportunity to observe staff training in adult protection. It was very evident Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 16 that all staff undertaking the training participated positively and really contributed to the workshop. However thought needs to be given to the preparation and presentation of in-house training packages. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The safety of service users is not adequately maintained. EVIDENCE: The home has an accessible extremely well maintained pleasant garden with a water feature; in the hot weather the service has erected shades for service users to sit under. The inspectors toured the building and noted some short corridors that lead to dead ends that are not conducive to service users with dementia mobilizing safely. At one of these dead ends it was observed that the homes electricity fuse box cabinet was located and noted with concern that the cabinet was unlocked and ajar. The inspectors observed that fire doors that prevent the spread of fire and smoke through the building in the event of fire were not fitting into their frames and therefore ineffective. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 18 Some carpets throughout the home are stained and require either deep cleaning or replacing. It was also noted that a bathroom with toilet and the home’s laundry were carpeted. This is not conducive to good hygiene and the prevention of the spread of infection. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are insufficient staff on duty who themselves are not adequately trained or supported. EVIDENCE: Inspection of the home’s rota evidenced that shifts were divided into quite short periods with varying numbers of staff in the home during these times. Between the hours of 8am and 9pm there are three shifts with five staff on the first shift, four on the second shift from 1pm to 6pm and then the levels drop to 3 carers between 6pm and 9pm. There are 34 service users in the home many with dementia and this level of staff is inadequate. When there are 4 staff on duty between 1pm and 6 pm then this means there is only one member of staff to care for between 8 or 9 service users. When 3 staff on duty between 6 and 9pm this means there is only one member of staff to meet the needs of between 11 or 12 service users. Obviously the level of support service users require will vary and this is currently an unknown quantity as there are no care plans to describe the level of support given. The inspectors observed quite a few service users who appeared to need considerable support, and service users who just time spent with them. Within the body of this report there are several indicators that there are insufficient staff on duty. Such as service users being found after an accident with no witnesses, service users being assisted to rise early by the night staff, service users being served meals in their arm chairs as getting people mobilised and transferred to the dining tables is time consuming, serving tea with milk already mixed in the teapot because it is “easier to do that way” and Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 20 the lack of a structured activity program that meets the needs of all service users. The service has been required by the Commission to review their staffing levels and has failed to do so. It is evident that these levels must be revised and increased to adequately meet the needs of service users. The home has a book that staff sign in at the beginning of their shift and out as they are leaving. However it was noted that on the night before the inspection staff had signed in on duty and then signed out at the beginning of their duty. The inspector spoke with one of the staff who was actually still in the home thirty minutes the time stated. It is crucial that this record is an accurate reflection of who is in the building at any given time. The inspector checked the random selection of staff files to test the services recruitment process. On one file checked there was no photographic identification, references were also missing. There was evidence that an application/CV and CRB gave conflicting information about the applicant’s employment history and there was no evidence that the home had sought to clarify this. Records revealed that the home has less than 50 of its staff them with NVQ level 2, which was a target, to be achieved by 2005. The inspector was concerned to note a NVQ award certificate that appeared to have been altered. The manager was asked to obtain the original award and advise the Commission accordingly. On checking staff files the inspector could find no evidence that staff had had received an induction at the beginning of their appointment. It was noted that not all staff have training in dementia care and this is of concern. There were four staff on duty on the early morning when the inspector arrived, it was noted that only one of these had certificates to evidence of dementia care training. . Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for some time now and has experience of working with older people. She has not yet completed her NVQ 4 award. The issues highlighted in this report indicate that the registered manager needs undertake more training to enable her to lead the staff team in developing a responsive service for people with dementia. From reading the communication book, staff complaints book, and handover book there inspector observed some less than positive relations between some of the staff team. The last recorded staff meeting was over a year ago. This is inadequate it offers staff very little opportunity to influence the way the service Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 22 is delivered and reduces management’s ability to address issues and offer a sense of direction. The manager has sent out questionnaires to service users relatives all of those seen by the inspector were positive and complimentary about the service. The inspector was pleased to read such feedback. The service will need to begin actively seeking the views of service users in a manner suited to their communication needs. The home holds for service users cash deposited by families or court of protection. The inspector checked the Three service users’ monies were checked against the balance recorded on the ledger. These were in all in order. The inspector discussed with the senior staff the need to improve the cash record sheet and was satisfied this was in hand. The inspector tracked two amounts of monies deposited by families in the home and whilst these were recorded on the cash record there was no evidence that relatives had been issued with a receipt. Staff files were checked to assess the adequacy of staff supervision. Three staff had supervision only one in 6 months and on other files checked there was no evidence of any supervision. This is evidence that staff are not receiving adequate support and guidance for the work they are expected to undertake. The inspector checked the homes record on fire safety. There was documented evidence that weekly fire points are tested and emergency lighting checked. Staff are also training with regular updates on fire safety. Although not all the home’s night staff have had recent fire safety training. The home undertakes regular fire drills three times a year it was noted service users are evacuated during these drills. This is a considerable upheaval and stress that may well not be necessary. It was noted that there fire drills did not record those staff taking part, it is necessary for the home to demonstrate all staff have taken part in a drill, particularly night staff. The home maintains a record of food storage temperatures, and hot water temperatures. The inspector was concerned to note that 8 litres of various COSHH products (corrosive) left on counter in an unlocked unattended office with the door open, immediately opposite a toilet used independently by service users. A COSHH product also found in a bathroom. Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 23 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 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X 2 X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 2 2 X 2 Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 24 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 The registered manager must ensure that the service has an up-to-date comprehensive assessment of need before service users are admitted to the home. Unmet requirement. The registered manager must ensure that the assessment of need highlights any specialist needs of prospective service users and the homes ability to meet them. The registered manager must ensure that all service users have comprehensive care plans in place that detail the actions required of staff to meet the service users needs. Unmet requirement The registered manager must ensure that each service user had a detailed risk assessment that fully identifies the risks and actions of staff to minimise the risks. Unmet requirement. The registered manager must ensure that all accidents are DS0000067137.V298078.R01.S.doc Timescale for action 01/09/06 2 OP4 14 01/10/06 3 OP7 15 01/10/06 4 OP7 13 01/10/06 5 OP8 12 17 01/09/06 Malvern House Version 5.2 Page 25 6 OP8 13 7 OP8 18 8 OP8 13 9 OP8 37 10 11 OP8 OP10 13 12 12 OP10 12 13 OP12 12 14 OP12 15 15 OP14 12 23 recorded in sufficient detail. The registered manager must ensure that service users receive prompt nursing or medical attention when required. The registered manager must ensure that staff receive training in the predisposing factors of pressure sores. The registered manager must introduce a system to demonstrate that accidents and falls in the home are monitored and appropriate management action taken. The registered manager must ensure that the Commission is notified without delay of any occurrences that affect the wellbeing of service users. The registered manager must ensure that all service users are moved and handled in a safely. To maintain confidentiality the registered manager must ensure that the service records issues pertaining to service users in their personal care records and not in general communication books. The registered manager must ensure that service user’s confidentiality and privacy is maintained. The registered manager must ensure a range of individual and group activities are introduced, including activities appropriate for people with dementia. Unmet requirement. The registered manager must ensure service users interests in social or leisure pursuits are recorded on their care plan. The registered manager must ensure that service users that requested locks to their private accommodation have an DS0000067137.V298078.R01.S.doc 01/09/06 01/10/06 01/10/06 01/09/06 01/09/06 01/08/06 01/10/06 01/10/06 01/10/06 01/10/06 Malvern House Version 5.2 Page 26 16 OP14 12 23 17 OP14 12 18 OP15 12 23 19 OP15 12 20 OP16 24 21 OP16 24 22 23 OP18 OP21 18 13 13 24 25 OP19 OP19 23 23 13 appropriate lock fitted. The registered manager must commence a program of fitting locks to service users rooms to offer service users real choice. The registered manager must ensure service users are not assisted to rise in the very early hours of the morning unless they expressly wish to do so. The registered manager must ensure service users are given the opportunity and support to eat their meals at a table. The registered manager must revise the homes process serving and presentation for food and drink to service users to ensure food is hot and service users exercise real choice. The registered manager must ensure the home complaints procedure is prominently displayed and appropriate to the communication needs of service users. The registered manager must ensure that all complaints about the care of service users regardless of source are recorded and thoroughly investigated and responded to appropriately. Unmet requirement. The registered manager must ensure all staff receive training in adult protection. The registered manager must ensure that carpets in the bathroom/toilets and laundry are replaced with an impermeable covering that can be readily cleaned. The registered manager must ensure that the all fire doors close into their frames. The registered manager must ensure that all electrical DS0000067137.V298078.R01.S.doc 01/12/06 01/08/06 01/09/06 01/10/06 01/09/06 01/09/06 01/10/06 01/11/06 01/10/06 01/08/06 Page 27 Malvern House Version 5.2 26 27 OP19 OP27 23 18 28 OP28 18 29 OP28 18 30 OP29 19 31 OP30 18 32 OP30 18 33 OP36 18 34 OP27 18 17 35 OP31 10 cupboards are kept locked. The registered manager must ensure that all stained carpets are deep cleaned or replaced. The registered person must review and improve upon the current staffing levels within the home to ensure service users needs are adequately met. The registered manager must provide the commission with a plan as to how the service aims to have least 50 of the staff team have an NVQ award. The registered manager must advise the commission of the outcome of her investigations into the apparent discrepancies in an award certificate. The registered manager must ensure that no-one is appointed to work in the home unless all the required documentation as detailed in schedule 2 of the CHR 2001. The registered manager must ensure that all staff have an appropriate induction at the commencement of their employment. Unmet requirement. The registered manager must ensure staff receive training in dementia care, recording, confidentiality, privacy, care planning and risk assessing. The registered manager must ensure that all staff have supervision at least 6 times a year, the record of which will be recorded. The registered manager must ensure that the staff rota and signing in book is an accurate reflection of all staff in the service at all times. The registered manager must undertake further training in DS0000067137.V298078.R01.S.doc 01/10/06 01/10/06 01/10/06 01/10/06 01/08/06 01/10/06 01/10/06 01/10/06 01/10/06 01/10/06 Page 28 Malvern House Version 5.2 36 OP32 16 37 OP33 24 38 OP35 13 39 OP38 13 40 OP38 23 41 OP36 13 dementia care, care planning and completed her NVQ4 award. Unmet requirement. The registered manager must ensure staff have regular meetings so they can affect the way the service is delivered. The registered manager must introduce appropriate ways of eliciting feedback form service users on the service provided and ensure their feedback is acted upon. The registered manger must ensure good accounting practices are adopted and that receipts are issued for monies received. The registered manager must ensure that Corrosive chemicals are stored securely in line with COSHH guidelines. The registered manager must ensure all staff including night staff have regular fire drills and fire safety training. The registered manager must ensure that all dangerous substances are securely and appropriate stored at all times. 01/10/06 01/10/06 01/09/06 01/08/06 01/10/06 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Malvern House DS0000067137.V298078.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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