Inspection on 27/02/07 for Maranatha Rest Home

This inspection was carried out on 27th February 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

Maranatha Rest Home 03/07/08

Maranatha Rest Home 17/01/08

Maranatha Rest Home 16/08/07

Maranatha Rest Home 20/10/05

Maranatha Rest Home 16/11/04

Maranatha Rest Home 13/07/04

Maranatha Rest Home 11/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Maranatha Rest Home 211 York Road Southend On Sea Essex SS1 2RU Lead Inspector Ms Vicky Dutton Unannounced Inspection 27th February 2007 09:00 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 Maranatha Rest Home DS0000038290.V331666.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. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maranatha Rest Home Address 211 York Road Southend On Sea Essex SS1 2RU 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) 01702 467675 01702 600884 Syed@smh.demon.co.uk AMA Generic Ltd Mrs Rosemary Gay Bodley Care Home 15 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (15) of places Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Training in the care of older people with dementia to be arranged for care staff three months from date of registration. Radiators within the establishment to be made safe, by ensuring both covers and thermostats are fitted where required. 23rd February 2006 Date of last inspection Brief Description of the Service: Maranatha Rest Home is an established private home providing personal care and accommodation for up to 15 older people. Within this number the home is registered to take up to 5 people who have a formal diagnosis of dementia. Maranatha is a detached property comprising of eleven single and two double bedrooms. There is a choice of two communal lounge areas, a dining area and a conservatory. Bedrooms are provided on the ground and first floor, with the first floor being accessed via the passenger lift. There is a small garden for the use of residents and on street parking for visitors. The home is situated close to Southend town centre and to the seafront. Maranatha has a statement of purpose and service users guide available. (see standard one) Copies of these documents were available in the entrance hall of the home. The inspection report available to residents/other interested parties dated from October 2005. An inspection of the home has taken place since this time, but the report is not yet published. It was confirmed that the current fees at the home are £386.00 to £450.00 There are additional charges for chiropody, hairdressing, and individual choice newspapers/magazines. Maranatha Rest Home DS0000038290.V331666.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 site visit undertaken as part of the key inspection for the home. The site visit took place over a period of seven hours. At this visit all the key standards, and the homes progress against their previous agenda for action were assessed. Prior to the site visit the home had submitted a pre-inspection questionnaire, and provided additional information that assisted with the inspection process. At the site visit a tour of the premises took place, care, staff, and other records and documentation were selected at random and various elements of these assessed. During the site visits residents, and some of the homes staff were spoken with. As part of this key inspection questionnaires were sent out in the post to health and social care professionals. Staff, residents and relatives/visitors surveys were left at the home at the site visit. The views expressed at the site visit and survey responses have been incorporated into this report. The inspector was assisted at the site visit by the registered manager and deputy manager. Feedback on findings was given throughout the visit, and summarised at the end of the visit. The opportunity for discussion or clarification was given. A feedback card on the inspection process was left at the home. The inspector would like to thank the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: In discussion and through surveys positive feedback was given about the home from residents and relatives. One resident said ‘It’s lovely here, I would not want to live anywhere else.’ Another said, ‘the staff here are very good.’ A relative said ‘I and my family know that everything is done well, we can’t find fault at all.’ Another said ‘The home is not a palace, but the loving care residents receive from staff is second to none.’ Visitors are always made welcome at Maranatha. The staff group at the home have mostly worked there for some time. This provides consistency and stability for residents. Staff are caring and treat residents as individuals. Staff were positive about the home and felt that, ‘there is always a good and happy atmosphere.’ Staff felt that good training Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 6 was offered to help them to meet resident’s needs and that they were well supported by management at the home. The home works well with visiting professionals. What has improved since the last inspection? 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. Maranatha Rest Home DS0000038290.V331666.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 Maranatha Rest Home DS0000038290.V331666.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): 1, 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service users guide need to be reviewed and updated so that they provide current information to residents. Assessments are undertaken before residents move into the home. EVIDENCE: The homes Statement of Purpose and Service Users Guide date from January 2004. Since this time Regulations relating to the information that needs to be included in the service users guide have been updated. The home has also become non smoking for residents. These documents therefore need to be reviewed and updated so that potential residents are offered up to date information about the home, to assist them in making a decision about if the home will meet their needs. The home also need to ensure that the format of the service users guide is suitable and ‘user friendly’ for the people who will use it. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 9 The files of two recently admitted residents were viewed. These showed that staff from the home visit potential residents and assess their needs before they are admitted to the home. Information was also available from hospitals and social workers. Intermediate care is not provided at Maranatha. Maranatha Rest Home DS0000038290.V331666.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s individual care is not based on a clear assessment and planning process which residents and staff are involved with. Anecdotally residents receive good healthcare, but again this is poorly documented and evidenced. Staff at the home are caring and treat residents with respect. EVIDENCE: Observations and feedback from residents and relatives showed that residents feel that their care needs are met. One relative said ‘The care residents receive from assistants is very good.’ Staff observed and spoken with had a good awareness of residents as individuals. However, as at least the previous two inspections, this site visit showed that care planning at the home is still poor, and does not provide an adequate basis for the delivery of holistic care to residents. This has the potential to place residents at risk. Four care plans were viewed during the site visit. All showed significant shortfalls. Information from assessments had not become part of the care plan. For example it was identified that one resident needed to be Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 11 assisted to the toilet. This was not identified in the care plan, with instructions for staff as to the best way to manage this, detail frequency and so on. Care plans did not always reflect resident’s current needs. For example it was stated that one resident had a catheter in place when this was not the case. For another resident behavioural issues and significant health needs were identified in various documentation seen in the care file. No comprehensive and up to date care plan drawing all this information together, with clear instructions for staff, could be found. A resident who suffers from dementia and attends the home for day care had no care plan in place at all. The manager undertook to address this during the site visit. Information in care files was often jumbled, and not dated making it difficult to establish what information was current. There was nothing to show that residents/relatives had been proactively involved in the care planning process. Daily records are maintained separately from the care files in individual residents diaries. Care staff record three entries a day in these. Other information relating to residents, for example bath/weight records and nutrition records are also kept separately This is not good practice, and has the potential to compromise good resident care by increasing the risk that important information/developing issues will be missed and not acted upon. The practice also does not encourage care staff to make active use of care planning information. Staff recognised that there are sometimes problems. One said ‘things are sometimes not passed on, so therefore are not carried out as they should be.’ And, ‘sometimes information is misinterpreted or misunderstood, but it is sorted out in the end.’ It is clear that care plans at the home are not routinely used by care staff, but that the home relies on verbal sharing of information. ‘Most of the time they tell us information concerning residents health, e.g. allergies and other conditions they have like deafness etc.’ A proper assessment, care planning system and staff involvement needs to be developed in order that all residents health, social, and cultural needs are properly identified and met. At the previous inspection of the home, a year ago it was identified that: ‘At this inspection detailed discussion took place with the registered manager/deputy manager as to the Care Homes Regulations/National Minimum Standards for Older People pertaining to care planning/risk assessing.’ It is concerning that limited progress seems to have been made in this area. From discussion and observation it was evident that residents healthcare needs are monitored and catered for. One resident said that when they need antibiotics for their legs this is always acted upon very quickly. It was also positive that a continence advisor was visiting the home during the site visit, showing that resident’s continence needs are assessed. Positive feedback was received from visiting professionals. One said ‘I would be happy to live here when my time comes.’ The registered manager said that the home maintained very good working relationships with visiting professionals. Feedback from one Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 12 said. ‘Staff are always welcoming to visiting professionals and make every effort to include professionals in decision making/ideas for the home.’ The area of healthcare however is again let down by poor record keeping potentially putting residents at risk through staff not being aware of any developing issues. The manager recognised this and said that issues are discussed within the staff group, but not necessarily written down. (See also above.) Assessments seen in care files relating to, for example, nutrition were not always fully completed. An area highlighted for urgent action was that two staff at the home are routinely and regularly testing a residents blood sugar levels. It was stated that training for this was undertaken about two years ago. Since the initial training, competence has not been reassessed. There was no protocol in place showing that the district nursing service retained responsibility for this procedure, and what monitoring/competence reassessment processes would be in place. There was nothing in the residents care plan relating to this practice, and the care plan was in any event out of date. The resident was reported as being confused and the issue of consent for care staff to carry out this task had not been thought about or addressed. During the site visit staff were also observed to be taking a residents blood pressure. It was confirmed that the machine belonged to the home. The home is not registered to provide nursing care so should not routinely be carrying out such tasks. So that residents are protected the home should only carry out such tasks when asked to do so by a medical professional for a specific need. This must be properly documented in residents care records. Staff must be trained and competent in the use of any equipment. If a home has its own equipment it must be evidenced this is regularly maintained and checked for accuracy. Medication at the home is managed mostly through a monitored dosage system. (blister packs) Records were well maintained and staff were able to confirm that they had undertaken training in the administration of medication. The system is generally managed in a way that safeguards residents. However the following practice issues need to be addressed: • The management of creams and topical applications needs to be improved. A tour of the premises revealed a number of creams in use in resident’s bedrooms that were not labelled, or where the label was worn and not legible. • Boxed/bottled medication should be dated when opened/commenced. • Where spacer devices are used to assist resident’s who use inhaled medication, these should be maintained in a clean and hygienic condition. • Handwritten entries on the medication record should be double signed by staff. • Medication should be properly booked in and accounted for on all occasions, as this was not the case for a day care resident. Staff at the home were seen to treat residents with care and respect. Their privacy was respected. The issue of confidentiality was raised in relation to the Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 13 office area where information on whiteboards, letters relating to individual hospital appointments and so on were clearly on display. The manager said that only staff used this area. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities are provided at the home, but development is needed to make sure that these are in line with residents assessed needs and expectations. Visitors are made welcome at the home. Residents were satisfied with the food provided. EVIDENCE: The home does not use a formal programme of activities. Care staff undertake activities such as cards, skittles, exercises and craftwork on an ad hoc basis. During the morning a member of staff undertook some exercises with residents. The member of staff had a very good rapport with residents. Some staff at the home have completed training on ‘Activities in a Care Home.’ Residents reported being happy with the level of activity offered and particularly said that they enjoyed a sing-along with an entertainer who visits the home each week. Staff however identified activities for residents at the home as an area that could be improved upon. Anecdotal evidence was given relating to residents individual needs being addressed by them being offered occupational opportunities such as helping in the kitchen. Although some preferences are recorded resident’s activity/occupational needs are not fully assessed and planned for. The home is registered to provide care for five Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 15 residents who have dementia therefore this area needs development. Resident’s participation in and reaction to activity/occupation is not routinely recorded, making it difficult to gauge the success in offering individuals appropriate stimulation. So that residents are cared for safely occupational activities should be risk assessed as appropriate. Visiting at the home is open with no restrictions. Feedback showed that people felt that they were always made welcome at Maranatha. Relatives felt that they could always talk to staff and receive a good response. One said ‘Staff are very good and always there to answer any questions.’ Residents at the home are able to bring in personal possessions. A policy on the use of advocacy services was available, but no information was readily available for residents or families. The registered manager undertook to address this. Lunch on the day of the site visit looked appetising and was enjoyed by residents. Menus are based on one main meal with alternative choices such as salad, omelette, soup or other items being available. Residents said that they were happy with the food provided at the home. The main meal times at the home have short spaces between them with breakfast starting at about 08.00, lunch at 12.30 and tea at 16.30. Supper is served later for residents who might still be up. The manager said that this would be flexible and take into account individual residents preferences. The homes dining area does not provide sufficient seating for the number of residents living at the home. The manager reported that some preferred to eat their meals in the lounge areas and that additional seating would be provided if necessary. Maranatha Rest Home DS0000038290.V331666.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 adequate. This judgement has been made using available evidence including a visit to this service. No concerns have been recorded by the home or raised with CSCI. To ensure residents are kept safe staff have been trained in adult protection. Management do however need to make sure that all staff are clear about reporting procedures. Training in managing challenging behaviour has started. This needs to be undertaken by all staff, and backed up by clear care planning where appropriate to meet the needs of residents. EVIDENCE: The homes complaints process was on display on a notice board in the home. It was not clear that there was an effective system in place for recording any complaints or concerns raised with the home. Only an ‘occurrence book’ was available. No complaints or concerns had been recorded by the home. No complaints or concerns about the home have been raised with CSCI. Residents and relatives said that they would feel confident in raising any concerns with the staff or manager. Staff reported in surveys that they knew what to do if someone raised concerns with them. Most staff at the home have received training in adult protection. Information on this subject was readily available in the home. Care staff spoken with understood issues around abuse and whistle blowing. A senior member of staff however was not fully clear about reporting procedures. One member of staff so far has received training in managing challenging behaviour. At the Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 17 moment at least two residents at the home can present with challenging behaviour. As previously indicated care plans provide little in the way of constructive instruction to staff in managing these situations. Maranatha Rest Home DS0000038290.V331666.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, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Maranatha provides a homely environment. However many areas of decoration and furnishings are becoming shabby, and most areas of the home need to be upgraded. A programme of renewal and redecoration needs to be developed and started to improve the environment for residents. EVIDENCE: Maranatha generally provides a comfortable and homely environment for residents, but many areas are in need of upgrading and refurbishing to a better standard. Residents said that they were happy with the accommodation offered. Access to the main entrance of the home is via a flight of steps. Wheelchair access is to the side of the building. A small garden for the benefit of residents is provided at the back of the building. Since the previous inspection two bedrooms and a small corridor area at the home have been refurbished due to fire damage. Other areas of the home Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 19 require similar attention. The laundry, kitchen, bedrooms and communal areas of the home all need attention. Relatives also felt that the environment of the home needed urgent attention and comments such as: ‘Bedroom furniture could be replaced as most pieces are at a low ebb,’ ‘the kitchen bathroom and toilet facilities are all in need of modernisation,’ ‘the home would benefit from complete refurbishment, furniture in the bedrooms is not good,’ and ‘the kitchen needs modernisation and the lounge desperately needs refurbishing.’ Relatives also raised concerns about the lack of hot water in some areas of the building, particularly bedrooms. A new boiler has just been fitted at the home. Future inspections will assess if this has resolved the situation. As relatives identified, furnishings in many residents’ bedrooms are becoming extremely shabby and would benefit from replacement to improve the environment for residents. Call points in a number of areas were not fitted with cords. This could make it difficult for residents/staff to summon help if required. No programme of routine maintenance and renewal was in place to show that any improvements are planned. The home is registered to provide some dementia care. This needs to be considered to a greater degree with issues such as signage, safety (see standard 38) and things such as clocks saying the wrong time being addressed. One visiting professional felt that residents would benefit from some areas being better lit, to increase their safety. The home is generally kept clean, but some attention to detail is needed to ensure good infection control. In one bathroom un-bagged used incontinence pads were in an open unlined bin. Items such as toilet seats being in poor condition also does not assist good infection control. To promote infection control the home encourage staff to use of alcohol gel, which is sited in risk areas. Apart from one isolated area odour control at the home was satisfactory. The manager undertook to address the issue in this area. The home has a laundry area that is sufficient to meet the needs of the home. This area is not kept locked and this should be risk assessed to make sure that residents are kept safe. The external door in the laundry was in poor condition and not fully weatherproof. Staff confirmed that they have received training in infection control. Maranatha Rest Home DS0000038290.V331666.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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing at the home is stable and agency staff are not used. Staff recruitment processes need to be improved so that they fully protect residents. Staff receive training to help to care properly for residents. EVIDENCE: Staff rotas were viewed and showed that staffing levels are being maintained at three staff on duty during the day, with one being in charge, and one asleep and one awake staff at night. The registered managers hours are normally supernumerary to this. At the moment the cooks hours are mostly being covered by the registered manager or deputy manager. Staff also identified that they also have to cook on occasions and felt that a cook should be appointed. Domestic hours are provided for three hours a day. The registered manager felt that current staffing hours were sufficient to meet the needs of residents. Residents spoke very positively of staff at the home and said that help was always available when they needed it. Feedback from staff was that at times of high demand more staff would be beneficial, as ‘we may not have time for everyone.’ Maranatha benefits from having a stable staff group. Many staff have worked at the home for a number of years. This provides consistency for residents. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 21 Out of fifteen staff at the home none currently hold a National Vocational Qualification (NVQ). It was reported that one member of staff is undertaking NVQ at level three and one at level two. It is planned that a further three care staff will be signing up to undertake NVQ courses. The home falls well below the recommended standard of 50 of care staff at the home being trained to NVQ level two or above. The inspector was told that only one new member of staff had been recruited since the previous inspection. On viewing this file, it was not evidenced that recruitment practices at the home are robust enough to protect residents. The application form was poorly completed and did not provide a satisfactory employment history. No POVA first check was in place. The persons Criminal Records Bureau (CRB) check dated from January 2005 and was from a previous employer. There was no recent photograph or evidence of previous qualifications. A further staff file looked at was better but there was again no current CRB check in place. Shortfalls in recruitment procedures were raised at the previous inspection of the home. To help new staff to offer good care to residents the home is undertaking staff induction based on the Skills for Care common induction standards. The documentation relating to this could not be viewed, as it was said to be with the members of staff. However supervision records showed discussions about progress and understanding of the common induction standards. Staff felt that the training opportunities offered by the home were very good, and identified a range of training that they had undertaken, including dementia care. One said ‘The training courses that I go on are very helpful to me, and I can therefore practice good care towards my residents.’ A training matrix showed that staff at the home undertake some appropriate training, (see also standard 38.) Maranatha Rest Home DS0000038290.V331666.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, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager at Maranatha is experienced and has/is undertaking relevant qualifications. Findings of this report have shown that although outcomes for residents are generally satisfactory, work is needed to make sure that care is delivered, and the home managed in line with the National Minimum Standards for Older People. The home needs to be properly regularly monitored to identify and as far as possible eliminate health and safety hazards to residents and staff. EVIDENCE: Maranatha has an experienced registered manager in post. They are currently undertaking their Registered Managers Award and NVQ level four in care. It is hoped that these qualifications will be completed by the end of March this year. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 23 Staff and residents felt that the registered manager was very approachable and a strong presence in the home. The manager adopts a very ‘hands on’ approach to their role. As seen in this report management at the home needs to focus on developing and monitoring robust systems that promote well evidenced resident care, and provides for the health and safety of residents and staff. The registered provider has strategies in place to monitor the quality of the service at Maranatha. A quality control exercise utilising questionnaires to seek resident’s views was undertaken last year and was reported to be in the process of being completed for this year. This work should help to form an annual development plan for the home. The report and information from this exercise must be made available to residents and other interested parties. The registered provider also conducts regular visits to the home to carry out visits that are required by Regulations. The home is also part of the Investors in People scheme, and has recently been re-accredited. The home has just started to hold personal allowances on behalf of residents. A new process is therefore in place that will be more fully assessed at the next inspection. On this occasion monies held were accurately recorded. Staff at the home reported feeling well supported by management, and confirmed that they had regular one to one supervision sessions with the manage. Records of these sessions showed that appropriate topics are discussed and recorded. A number of health and safety issues were identified as part of this inspection. Some of which have already been identified. A new boiler had been installed leaving exposed and hot pipes running close to a toilet in a resident’s en suite area. In a follow up discussion the manager confirmed that works were planned to box these in within a few days. A side door off the dining room was open allowing access to the side of the house and an adjacent unlocked gate to steps to a basement area. In feedback from relatives following the site visit they said that the security of the front door locks was suspect. In a follow up discussion the manager confirmed that the side gate at the home was now secured. The homes electrical certificate expired in August 2006. Two relatives also expressed concerns about the electrical systems at the home as ‘light bulbs frequently blow.’ It was confirmed that electrical works will be actioned as a matter of urgency and a copy the new certificate forwarded to CSCI. The kitchen area of the home needs attention. Some work surface areas are worn, and some door/cupboard fronts missing. Food stocks are stored in an external shed area, with dried/cleaning products being stored in the same area. The home received a visit from an environmental health officer in 02/11/06. The report from this visit was not viewed but the registered manager said that no issues were raised. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 24 Staff training in core areas such as moving and handling was difficult to evidence. The deputy manager was trained in 2005 to be a moving and handling trainer/assessor. Although it was felt that training/update training had been undertaken with staff, no evidence of this was available. The homes training matrix (for 2006) did not show that staff had undertaken moving and handling training. Staff training records need to be consolidated so that it can be easily seen that staff have received appropriate core training and can care safely for residents. Fire records were satisfactory, but it was advised that a better record be kept of which staff have attended fire drills. Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 1 Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(1) Requirement The registered person(s) must prepare a written plan as to how the resident’s needs in respect of their health and welfare are to be met. This refers to the issues raised in the body of the report, and discussed at the site visit. These relate to serious shortfalls in the care planning system and associated documentation relating to the meeting individuals care needs. Previous timescales of 01/02/06 and 01/07/06 not met. 2. OP8 12, 15 The registered person(s) must make proper provision for the health and welfare of residents. This refers to the issues raised in the body of the report, and the need to the need to properly document resident’s health care needs, planned interventions and outcomes. Residents must be protected by proper protocols and procedures being in place for Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 27 Timescale for action 01/04/07 01/04/07 planned interventions. 3. OP9 13 The registered person(s) must 01/05/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into a care home. This refers to the need to have a proper process in place for the management of creams and topical applications at the home. Other practice issues raised in the body of the report also need to be addressed. 4. OP19 23 The registered person(s) must ensure that the premises are suitable to meet the aims and objectives of the home. This refers to the issues raised in the body of the report, including the need for a plan of redecoration and renewal, and of better facilities being provided to meet resident’s specialist needs. 5. OP29 17(2), 19, The registered person(s) must ensure that robust and safe recruitment procedures are adopted at all times and records as required by regulation are available at all times. (Previous timescales of 01/01/06 and 01/06/06 not met. 6. OP33 24 The registered person(s) must establish a system for reviewing and improving the service. Copies of any review reports must be made available to residents and other interested parties. The registered person(s) must DS0000038290.V331666.R01.S.doc 01/06/07 01/04/07 01/06/07 7. OP38 23 14/03/07 Page 28 Maranatha Rest Home Version 5.2 ensure that the premises are properly maintained. This refers to the need for a current electrical safety certificate to be in place for the home. A copy of a current certificate to be sent in to CSCI. 8. OP38 12 The registered person(s) must make proper provision for the health and welfare of residents. This refers to the need to assess and monitor health and safety matters at the home, and address the health and safety issues identified in the report. The registered person(s) must ensure that staff receive training appropriate to the work they are to undertake. This refers to the need to evidence that staff are trained and up to day in moving and handling procedures. 01/04/07 9. OP38 18 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The registered person(s) should review the homes Service Users Guides and Statement of Purpose to ensure that they provide up to date information, that is in line with current Regulations, for potential residents and other interested parties. The registered person(s) should review the practice of maintaining daily records, and other individual residents records, separate from care files. DS0000038290.V331666.R01.S.doc Version 5.2 Page 29 2. OP7 Maranatha Rest Home 3. OP10 The registered person(s) should review how information is stored in the office area of the home to make sure that resident’s confidentiality is protected. The registered person(s) should continue to develop appropriate activities and occupation in consultation with residents. In particular residents with dementia should have their needs properly assessed, appropriate occupation provided, and outcomes recorded. Information on advocacy services should be available for residents and their relatives. The registered person(s) should review the spacing of meals at the home to make sure that meals are spaced regularly without a long gap between tea/supper and breakfast. The practice of residents remaining in easy chairs for meals should also be kept under review to ensure that it is in line with their preferences, and does not compromise their health or welfare needs. The registered person(s) should ensure that staff are clear about POVA reporting procedures and would react appropriately in the event of an incident. The registered person(s) should audit and monitor the home to ensure that good infection control procedures are maintained. The registered person(s) should ensure that staff are encouraged and facilitated to achieve National Vocational Qualifications. 50 of care staff should achieve NVQ Level 2 or above. The registered person(s) should ensure that the home is run in a competent manner in line with Regulation and the National Minimum standards. 4. OP12 5. 6. OP14 OP15 7. OP18 8. OP26 9. OP28 10. OP31 Maranatha Rest Home DS0000038290.V331666.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Maranatha Rest Home DS0000038290.V331666.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. Re-publishing this information is in breach of the terms of use of that website. 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