Inspection on 29/06/07 for Malvern House

This inspection was carried out on 29th 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

Malvern House 30/11/09

Malvern House 26/11/07

Malvern House 20/03/07

Malvern House 19/06/06

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 Harbinder Ghir Unannounced Inspection 29th June 2007 09:50a 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.V340058.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.V340058.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 info@malvernresthome.co.uk Malvern House Retirement Homes Ltd Carol Ann Rolph 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.V340058.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 20th March 2007 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. The current fees range from £460- £512 per week. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two Regulation Inspectors Harbinder Ghir and Zita McCarry. The inspection took place on the 29th June 2007 between 9.50am and 5.00pm. The registered manager and one of the directors of the home were available throughout the time to aid the inspection process. During the inspection the inspector was able to talk to the service users residing at the home, staff and relatives who were visiting during the inspection. Relatives were also contacted by phone. As part of the inspection the inspector toured the home, read records of people who use the service and examined documents in relation to the management of the home. At the end of the inspection the inspectors were able to provide feedback to the manager of the home. Whilst the service continues to fail to meet the National Minimum Standards in many areas of care the Commission for Social Care Inspection positively notes that the home is making progress in addressing these shortfalls. The inspector would like to thank everyone involved in the inspection process. What the service does well: What has improved since the last inspection? Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 6 The service now completes life histories as part of their assessment process. Staff have received training in manual handling to ensure they are adequately equipped with the skills to meet service users’ needs. All fire doors have undergone maintenance work and now fit into their frames. The current staffing levels have been reviewed and improved to ensure service users needs are adequately met. The service no longer uses reclining chairs for service users who may be at risk of restraint by the equipment. 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. Malvern House DS0000067137.V340058.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.V340058.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): 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are not completed for all residents prior to moving into the home, which does not assure service users’, needs will be met by the service. The service does not provide intermediate care, EVIDENCE: The service has introduced a new pre-admissions assessment format. Five care plans were closely examined, but not all care plans viewed included a preadmission assessment. For Local Authority funded residents, the service had obtained care management assessments from the placing authority and health care services. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 9 However, there was no evidence of the service confirming in writing to service users that having regard to the assessment, the care home is suitable for the purpose of meeting perspective service user’s needs in respect of their health and welfare. This will be stated as Requirement 1. It is Requirement 2 that service users are only admitted on the basis of a full pre-admission assessment completed by the service. The service has begun to complete life histories and make reference to service users’ social backgrounds, particularly for those service users with a diagnosis of dementia. On one file viewed information was obtained in regards to the residents’ work life, social likes and religious preferences. However, this information was not utilised in care plans devised by the service. This will be discussed in more detail under standard seven of the report. Without robust pre-admission assessments, the registered persons cannot be certain that they can meet the total needs of a prospective resident. They also cannot be certain that they will be accepting someone who’s needs are within their conditions of registration and the aims and objectives of the service, as are set out in the Statement of Purpose. Malvern House DS0000067137.V340058.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): 7, 8, 9, 10, 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care planning system needs further improvement to ensure the needs of people who use the service are met. Medication administration practices are not safe, do not ensure the safety of people who use the service. The needs and wishes of residents in the event of death are identified and recorded, ensuring service users’ will be treated with care, sensitivity and respect at the time of their death. EVIDENCE: A new care plan format has been introduced by the home following the requirements made at the last inspection. The format covers all areas of need as identified by standard three of the National Minimum Standards. However, care plans require further improvement in detailing the tasks and outcomes to Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 11 be achieved by the service. Five care plans were closely examined. One care plan failed to identify a service user’s health care needs adequately and her dislike of wearing a hearing aid. On speaking to the service user’s son he informed the inspector that his mother “Does not like wearing a hearing aid and very often hides it.” He informed, “She was admitted to the home with the aid but does not know where it is now.” The care plan included no information in regards the service user’s dislike of wearing a hearing aid or any reference being made to the hearing aid missing. The relative further informed his mother “Hates wearing incontinence pads and has been very incontinent in the past but this has stopped since moving to a ground floor bedroom, and that she is supported to go to the toilet regularly by staff.” The care plan made no reference to the service user requiring this support but made reference to the service user as incontinent and wearing pads. Care plans also included brief information in service users’ dietary needs identifying their likes but not all care plans covered service users’ dislikes. Limited information was provided in regards to service users mental health needs. A service user at the home was observed to wander and was confused requiring the support and assistance of staff consistently. The service user’s care plan did not identify a diagnosis of dementia or her need to wander and how staff are to support her mental health needs. It is Requirement 3 that service users’ health, personal and social care needs is set out in detail in their care plan and ways to achieve the identified outcomes are clearly documented. The daily case records of daily events and occurrences were not recorded in detail. A care plan viewed evidenced the intervention of an Occupational Therapist who had implemented an exercise plan, which was pertinent in improving the service users mobility. There was no evidence in the daily case recording to reflect that the exercise plan was being followed or if the service user was supported by staff to complete these exercises. Daily case recording must reflect the actual care and support provided by staff, which must be recorded in detail. This is Requirement 4. The service has not promptly contacted health professionals. It was concerning to find that a District Nurse had been contacted when a service user’s pressure sore had become a grade two sore, which now requires ongoing treatment. To ensure the health of service users’ does not deteriorate health professionals must be contacted promptly particularly on the incidence of pressure sores. This is Requirement 5. The accident and incident book was reviewed. Discrepancies and inconsistencies were found in recording of accidents. Accidents were not recorded in full, and one form had no record of the date of the incident occurring. Not all service users were regularly checked after their accident and follow up sheets were not completed for all service users. The Commission for Social Care Inspection in line with Regulation 37 has not been informed of Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 12 some accidents where service users have sustained a fall, sustaining an injury and where subsequently an ambulance has had to be called. Risk assessments were also not reviewed in response to these accidents. The requirement in relation to the above findings will be stated as Requirement 6 and 6a. Care plans included weight-monitoring charts but service users did not undergo regular weight checks, as the charts were not completed consistently. Nutritional screening must be undertaken on a periodic basis and a record must be maintained of weight gain or loss and appropriate action taken. This is Requirement 7. Not all care plans viewed were signed by the service users or their representative. Service users or their representative should sign care plans to evidence that the service user or their representative agrees to the arrangement the home has made to meet their needs. This is Requirement 8. Service users spoken to by the inspector commented positively about the care they receive at the home. One resident spoken to stated, “Its alright here, I like it”. Another resident informed, “They are very good here, they look after me, I get me hair and nails done. The carers are lovely”. The inspector randomly selected service users’ medication records and tracked the medication being received into the home, which was not found to be in order. Medication received by the home was not all signed for by staff. For one service user a tablet was signed as administered but was not given. Medication received by the home must be accounted for and Medication Administration Records must be completed correctly to ensure the safety of service users. This is Requirement 9. Steps have been taken to find out the wishes of residents in the event of their death, including contacting relatives or representatives. Malvern House DS0000067137.V340058.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): 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. Limited social activities are arranged at the home, which do not meet the needs of those with a diagnosis of dementia. The meals in the home do not always offer variety or choice, and practices within the home do not always promote service users’ right to exercise choice. EVIDENCE: The activities coordinator was spoken to who is responsible for arranging activities for all service users. The activities book was seen which recorded activities completed and the residents who participated. Activities included live entertainment, games and puzzles, keep fit and sing a longs. Activities for residents’ with dementia or confusion as informed by the activities coordinator included a one to one “pedicure session where we talk about the past”. There was no evidence of specialist therapeutic interventions or approaches adopted by the service to meet the needs of service users’ with dementia, to establish Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 14 emotional security and a consistent sense of identity. This will be stated as Requirement 10. Limited evidence was found of service users being able to maintain outside community contact. One resident’s life history identified her need to attend church. This was not reflected in the service user’s care plan and no evidence was found of the home arranging for the service user to attend church. One relative spoken to positively highlighted that “I can visit my mother at any time and the home is very welcoming”. Another relative spoken to stated, “The home is very welcoming, and we can go as and when we like”. During the inspection relatives and friends were seen to visit throughout the day. It is Requirement 11 that community contact is promoted as service users wish and the service meets these needs. The daily communication book evidenced that some residents sleep in their chairs overnight and decline to go to bed. No record of evidence was seen of service users’ wish to sleep in their chairs or a risk assessment to ensure it was safe for them to do so. For those who residents who sleep in their chairs, it must be ascertained why residents do not want to sleep in their bedrooms. If it is their wish to sleep in their chairs this must be documented in service users’ care plans and a risk assessment completed to establish whether it is safe for them to do so. This is Requirement 12. During the inspection the inspector found it very concerning that choice and autonomy was not always promoted by members of staff. A service user at lunchtime on speaking to the inspector stated, “I don’t not want any more lunch,” and had clearly finished. A member of staff without asking the service user any questions began to spoon food the individual. This is poor practice and did not allow the service user to exercise choice and control. The registered person must conduct the home so as to maximise service users’ capacity to exercise personal autonomy and choice. This is Requirement 13. Evidence was seen of the cook talking to each resident about the choices of menu available for lunch. The menu for the day was also displayed in the dining room, which was in pictorial format. However, on viewing the menu the choice of meals was limited. During the day of the inspection it was a choice of two types of fishes with peas and potatoes, there was no other choice of any other meals for people who do not like fish or cannot eat fish. Food was served to residents already plated from the kitchen limiting service users choice on what is put in their plates. A choice of desert was not offered to residents, which was also not displayed on the pictorial menu board. It is Requirement 14 that a menu offering choice of meals is given to service users. Some service users were observed to be seated in their armchairs during lunchtime and were served their lunch on a small table in front of them. Not enough seating was provided in the dining room for residents to express a choice on whether they would like to join others at the table. Service users must be Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 15 given an opportunity and support to eat their meals at a dining table. This is Requirement 15. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure, which includes timescales within which a complaint is to be investigated, but timescales and the procedures are not followed by the service. Adult Protection policies, procedures are in place, but up to date staff training has not been provided to all staff in adult protection and does not ensure the protection of residents’ from abuse. EVIDENCE: The complaints procedure could not be fully tested at this inspection as no complaints have been received by the service since the last inspection. It would be unusual for any service not to have received any complaints within three months. All complaints, whether they are concerns or verbal complaints should be recorded without action being taken. The requirement therefore in relation to the services’ complaints practice will be repeated at this inspection as Requirement 16. The home has comprehensive policies and procedures and protocols to be followed in the event of an Adult Protection. Serious concerns were raised at the last inspection on staffs’ understanding of adult abuse and the protocols Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 17 they would follow and a requirement was made that all staff attend Adult Protection training. Training records identified that training in Adult Protection has been arranged by the service but not all staff have attended. This may mean that staff are unaware of abusive practice and people who use the service maybe placed at risk. The requirement will be repeated as Requirement 17. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home was satisfactory, providing residents with a homely and safe place to live. However, residents may be at risk due to infection control issues. EVIDENCE: A tour of the premises was undertaken. The home provides a warm and homely environment and in general the home is kept in good decorative order. A relative spoken to commented “We chose the home on its décor and it was clean when we visited. We are very happy with the home.” The communal areas in the home appeared clean and hygienic, however one Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 19 service user’s room seen by the inspector had an offensive odour of urine that required prompt attention and indicated the need for appropriate management. It is Requirement 18 that the premises are hygienic and free from offensive odours. Bedrooms were personalised by service users, by personal photos and furniture items. Some service user’s bedroom doors and a hallway door was propped open by pieces of furniture, which does not comply with fire regulations. It is Requirement 19 that fire doors are kept closed unless fitted with magnetic closures. During a tour of the building, bedside lighting was not working in some service users bedrooms and chest of draws in some bedrooms required repair or needed replacing. A toilet seat in a service user’s en suite bathroom also needed replacing. The storage room for laundry and the boiler room door was not locked during the tour. It is Recommendation 1 that all residents are provided with lighting, which is in working order, and live in safe, comfortable surroundings. Communal bathrooms were not provided with paper towels or soap dispensers increasing the risk of infection. A log of fridge, freezer and food temperatures was seen, which staff did not complete consistently as recordings were not found for some days. Food was also not stored in airtight containers. It is Requirement 20 that communal areas have systems in place to reduce the risks of infection and it is Requirement 21 that a daily log of food, fridge and freezer temperatures is recorded consistently and all food is stored in airtight containers. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment practices are not robust and do not ensure the safety of people who use the service. Staff training has improved but needs to be provided to all staff, to ensure they are trained and competent to do their jobs. EVIDENCE: The staff rota did not include the full names of staff on duty. It is Requirement 22 that the staff rota is an accurate reflection of the members of staff on duty. Staff numbers during peak times have been increased and during the day of the inspection, adequate numbers of staff were observed to be on duty. Two staff files were randomly selected to test the service’s recruitment procedures. The first file selected included a brief interview with evidence of only two questions being asked at the interview. Two references were found on file but it was concerning to identify one of the reference providers ceased to exist when checked. The second reference provider did not have any employment reference made to them on the applicants application form. The individual was appointed on a POVA check which is not in requirement with the Care Homes Regulations 2001. Both files had no evidence of each member of staff receiving an induction. It is Requirement 23 service users are supported Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 21 and protected by the homes recruitment practices, which must be more robust, and all new members of staff recruited must receive an induction. Staff training has been provided which included training in medication, POVA and adult protection, dementia, pressure sore awareness and manual handling. Not all staff have received training in these areas and this must be administered to the whole staff team as concerns were highlighted on staffs care knowledge. One member of staff who informed she was one of the directors of the home and that she was the shift leader for the day was not able to inform the inspectors of how many service users they had at the home with pressure care areas. Concerns were also identified at the conduct and practices of some members of staff. On the day of the inspection two members of staff were heard arguing and one member of staff was observed as becoming very frustrated and speaking abruptly to a service user who was confused. It is imperative all members of staff receive specialist training to ensure they can meet the needs of service users effectively. This is Requirement 24. The service does not have a ratio of a 50 NVQ qualified staff team. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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. Service users cannot be confident that the staff team who care for them benefit from regular supervision. Service users’ financial interests are safeguarded. The systems for service user consultation are poor with little evidence that service user views are sought or acted on. EVIDENCE: The significant number of recurring requirements from inspection to inspection in addition to new requirements gives the Commission for Social Care Inspection are of grave concern as to the effectiveness of the current Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 23 management arrangements. The service provider has confirmed the current manager is to leave who will be replaced by a new manager. A supervision programme is now in place but staff files evidenced that staff members are not supervised every two months. It is Requirement 25 staff are supervised at least 6 times a year, to ensure staff are provided with the skills, training and knowledge to perform the tasks required by their employment role. Services users’ records of finances were viewed and the inspector tracked the amount of money the service held for the service user. All amounts were accounted correctly and were in order. Evidence was seen of the service holding monthly service user house meetings to ensure service users have other means of expressing their views on the running of the home. Quality assurance surveys have been implemented by the service and evidence was seen of some completed surveys. No other evidence was seen of completed surveys by stakeholders and timescales had not been set in which surveys would be collected and collated. It is Requirement 26 that quality assurance surveys are completed regularly and timescales are set. The results are then communicated to residents and family and a copy of the results is made available to the Commission for Social Care Inspection. The service is now recording and completing regular fire drills. The health, safety and welfare of residents and staff is promoted and protected by the service completing regular audits of safe working practices. A wide range of records were looked at including fire safety and insurance certificates. These records were found to be up to date, and in good order. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 X 3 2 X 3 Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 25 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 persons must confirm in writing to service users that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of their health and welfare. The registered persons must ensure that service users’ have a comprehensive pre-admission assessment of need before they are admitted to the home. Repeated Requirement. Timescale of 25/06/07 not met. The registered persons must ensure that all service users have comprehensive care plans in place that detail the actions required of staff to meet service users’ needs. The registered persons must ensure the daily case recording reflects the actual care and support provided by staff, which must be recorded in detail. The registered manager must ensure that service users’ DS0000067137.V340058.R01.S.doc Timescale for action 30/09/07 2. OP3 14 31/08/07 3 OP7 15 30/09/07 4 OP7 14 15 30/09/07 5 OP8 13 31/08/07 Malvern House Version 5.2 Page 26 6 OP7 OP8 12 17 13 6a OP8 37 7 OP8 13 8 OP7 15 9 OP9 13 10 OP12 12 13 receive prompt nursing or medical attention where required particularly on the incidence of pressure sores. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must demonstrate that accidents and falls in the home are recorded in full and are monitored and appropriate management action is taken. Risk assessments must be reviewed accordingly. Repeated Requirement. Timescale of 25/06/07 not met. The registered persons must ensure that the Commission is notified without delay of any occurrences as detailed in regulation 37 of the Care Home Regulations 2001. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must ensure nutritional screening is undertaken on a periodic basis and records maintained of weight gain or loss and appropriate action taken. The registered persons must ensure service users or their representative sign care plans to evidence that the service user or their representative agrees to the arrangement the home has made to meet their needs. The registered persons must ensure medication received by the home is accounted for and Medication Administration Records must be completed correctly to ensure the safety of service users. The registered persons must ensure a range of individual activities is introduced appropriate for people with DS0000067137.V340058.R01.S.doc 31/08/07 31/08/07 30/09/07 30/09/07 30/09/07 31/08/07 Malvern House Version 5.2 Page 27 11 OP13 12, 16 (m) 12 OP14 OP7 12 13 13 OP14 12 14 OP15 12 15 OP15 12 23 dementia. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must ensure community contact is promoted as service users wish and the service meets these needs. The registered persons must ensure that each service user has a detailed risk assessment that fully identifies the risks and actions of staff to minimise the risks. If residents wish to sleep in their chairs, it must be identified why residents do not want to sleep in their bedrooms. If residents wish to sleep in their chairs overnight, this must be documented in service users’ care plans and a risk assessment must be completed. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must conduct the home so as to maximise service users’ capacity to exercise personal autonomy and choice. The registered persons must ensure the menu offered provides choice of meals to service users and they revise the homes process of serving and presentation for food and drink to service users to ensure service users exercise real choice. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must ensure service users are given the opportunity and support to eat their meals at a dining table. Repeated Requirement. Timescale of 26/06/07 not met. DS0000067137.V340058.R01.S.doc 30/09/07 31/08/07 30/09/07 31/08/07 31/08/07 Malvern House Version 5.2 Page 28 16 OP24 24 17 OP18 OP30 18 18 OP26 16 23 19 OP19 23 20 OP21 16 23 21 OP19 OP26 16 23 22 OP27 18 23 OP29 19 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 and all complaints are recorded centrally and held for inspection. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must ensure staff are adequately trained in adult protection. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must ensure premises are kept clean, hygienic and free from offensive odours. The registered persons must ensure all fire doors are kept closed unless fitted with magnetic closures. The registered persons must ensure communal areas are provided with paper towels and soap dispensers to reduce and control risks of infection. The registered persons must ensure a daily log of fridge, freezer and food temperatures is recorded consistently and that all food is stored in airtight containers. The registered person must ensure the staff rota includes the full names of all staff and that the rota is an accurate reflection of the members of staff on duty. The registered person must ensure that no one is appointed to work in the home unless all the required documentation as detailed in schedule 2 of the Care Homes Regulations 2001 is obtained. Repeated DS0000067137.V340058.R01.S.doc 31/08/07 31/08/07 31/08/07 31/08/07 30/09/07 31/08/07 31/08/07 31/08/07 Malvern House Version 5.2 Page 29 24 OP30 18 25 OP36 18 26 OP33 24 Requirement. Timescale of 26/06/07 not met. The registered persons must 30/09/07 ensure all members of staff receive specialist training to ensure they can meet the needs of service users effectively. The registered person must 31/08/07 ensure that all staff have supervision at least 6 times a year, the record of which is recorded. Repeated Requirement. Timescale of 26/06/07 not met. The registered persons must 31/08/07 ensure quality assurance surveys are completed regularly and timescales are set. That results are then must be communicated to residents and family and a copy of the results is made available to the Commission for Social Care Inspection. Repeated Requirement. Timescale of 26/06/07 not met. 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 OP24 Good Practice Recommendations It is recommended that all residents are provided with bedside lighting, which is in working order, and live in safe, comfortable surroundings. Unless an assessment of risk identifies that one is not required. Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Malvern House DS0000067137.V340058.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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