Inspection on 06/07/06 for Marian House

This inspection was carried out on 6th July 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

Marian House 18/11/08

Marian House 21/02/06

Marian House 06/09/05

Marian House 20/12/04

Marian House 16/08/04

Marian House 25/02/04

Marian House 22/10/03

Similar services:

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Marian House 100 Kingston Lane Uxbridge Middlesex UB9 3PW Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 6th July 2006 11:00 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 Marian House DS0000010934.V300086.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. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marian House Address 100 Kingston Lane Uxbridge Middlesex UB9 3PW 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) 01895 253 299 TRUSTEES OF SISTERS OF THIS SACRED HEART OF JESUS AND MARY Mrs Mamin Sawh Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 26 BEDS FOR ELDERLY FRAIL NURSING MINIMUM STAFFING NOTICE Date of last inspection 21st February 2006 Brief Description of the Service: Marian House Convent provides nursing home accommodation for 26 religious Sisters. It is a purpose built home with a chapel that is accessible to all the Sisters, regardless of their level of ability. The needs of the Sisters who live there are well catered for. All the bedrooms have en suite facilities and the communal space available is very well appointed. There is a separate section where the Community Sisters live. The home has spacious grounds and is near to Hillingdon Hospital. There are local amenities nearby. The home has a peaceful and happy atmosphere. The home organises a variety of entertainments following discussion with the Sisters. Television and music facilities are also available. The fees range from £387 to £750, dependent on the Sisters level of care needs. Marian House DS0000010934.V300086.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 carried out as part of the regulatory process. A total of 9 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 6 Sisters and 7 staff were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: Service user plans are generally well completed, with a review of the bedrail assessment required to fully identify the reasons for and appropriateness of Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 6 their use. In addition staff must not use correction fluid on service user documentation. Some improvements in the management of medications have been made, but it is important that action is taken to address the shortfalls identified in this report and thereafter ensure robust management of medications to ensure that shortfalls do not re-occur. The home is well maintained, and an up to date environmental audit from which a redecoration and refurbishment plan can be formulated is needed. Thereafter ongoing updates should be in place. Although staff recruitment procedures had been followed in most instances, clarification regarding Criminal Records Bureau checks was discussed at the inspection. Frequency of fire drills needs to be reviewed to ensure all staff participate in fire drills at the required intervals. 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. Marian House DS0000010934.V300086.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 Marian House DS0000010934.V300086.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 and 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to admission to the home, to ascertain that the home can meet their needs. Staff have received training in specialist topics to include dementia, and are thus able to meet the care needs of service users with such diagnoses. EVIDENCE: Prior to admission, a joint assessment from the relevant Social Services and the Primary Care Trust assessors is carried out and forwarded to the home in order for the Registered Manager to determine if the home is able to meet the needs of the Sister. Where no such assessment is available, the Registered Manager will visit and carry out her own assessment. This system is in place because due to the nature of the home Sisters are referred from several areas of the country. The assessments viewed were well completed and gave the home a good picture of the Sisters needs. Immediately on admission to the home a comprehensive needs assessment is carried out. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 9 Over the years some of the Sisters accommodated at the home have developed dementia care needs. Staff have received training in the care of dementia, and were seen caring for these Sisters in a caring manner. The home provides a separate sitting room for these Sisters, where they are supervised by a member of staff. Input has also been received from the Community Psychiatric Nurse Team. The need to apply for a variation to the homes registration specifically for the Sisters with dementia care needs was discussed with the Registered Manager. Marian House DS0000010934.V300086.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Although the medications are being generally well managed, shortfalls identified could potentially place service users at risk. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Four service user plans were sampled as part of the inspection. These were up to date and gave a good picture of individual needs and how these are to be met. There was evidence of monthly review, and of new care plans being developed where a new need had been identified. The service user plans are signed by the Sisters or their representative, to evidence their involvement in the service user plan. Risk assessments for falls are in place and there was evidence that the risk assessment plus all relevant documentation had been updated following a fall. The one shortfall noted in the service user plans was the use of correction fluid, which is unacceptable practice. The Registered Manager said that she would address this with the staff. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 11 At the time of inspection there were no Sisters with pressure sores. The Registered Manager said that when a need is identified the home does have access to the Tissue Viability Nurse Specialist. Pressure relieving equipment was seen in use in the home and this is clearly documented in the service user plans. Assessments for moving & handling, continence and nutrition had been carried out. The equipment to be used to meet individual moving & handling needs was clearly identified in the service user plan. For one Sister who had been at the home for convalescence, some additions were to be made to the service user plan due to the extended stay. The bedrail assessment document had not been reviewed since the last inspection. It does not accurately reflect the risk to the service user or record the suitability of use, and this repeat finding must be addressed. The service user plans evidenced input from healthcare professionals, and it was pleasing to speak with some of the Sisters who felt that their health is well cared for, and that they also feel much benefit from input from the Aromatherapist. The home has one GP who provides care for the Sisters, and who has done so for many years. Medication records were sampled as part of the inspection. Medications are stored securely in the home. Records of medication received, administered and disposed of were in place. Allergies are now recorded on the medication administration record (MAR). For one service user two of the blister packed medications needed reviewing by the dispensing pharmacist as one dose in each was incorrect. All other medication viewed was correctly dispensed. Instructions for two medications needed to be included in more detail so that each dose to be given was clearly identified. Liquid medications had not been dated when opened. All prescription creams and ointments are kept in the clinic room when not in use. Daily fridge temperatures are carried out. The clinic room was quite warm and the Inspector recommended that a room thermometer be placed in the room and the temperature monitored. If a reading above 25° centigrade is being recorded, then action should be taken to maintain the temperature at or below this. Where hand written entries had been made on the MAR these had not been signed. As a matter of good practice all hand written entries should be signed by the writer and by a witness. This instruction needs to be included in the homes medications policy, which was otherwise up to date. Although the medications are being well managed at most times, shortfalls were identified. With more attention to detail these shortfalls should be easy to address, and thereafter staff must be diligent in the management of medications in order to maintain a good standard. Staff were seen to care for the Sisters in a gentle and courteous manner, respecting their privacy and dignity. There is a good atmosphere in the home, and the staff work hard to care for the Sisters according to their wishes. The Sisters chosen term of address is recorded and respected. The Sisters clothing is individually labelled and well cared for. Staff have undergone training to provide them with the knowledge and skills to care for the Sisters needs. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The programme of activities is very specific to the needs of the service users, and respects their beliefs, interests and wishes. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the service users rights and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home is a Roman Catholic Convent for Religious Sisters. Therefore the daily routine centres round the religious services and observances throughout the day. In addition the Sisters are encouraged to decide what activities they would like to undertake, and on the day of inspection several had gone out shopping with care staff from the home. The Aromatherapist attends the home twice a week, and it was clear that the Sisters feel they benefit from this treatment. A volunteer with a ‘Pat Dog’ attends the home each week, which the Sisters enjoy. Musical entertainment is arranged in accordance with the interests of the Sisters. The Sisters are consulted about any activities that take place, so that the activities programme is arranged to meet their needs and wishes. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and can also provide accommodation for visitors travelling from a distance. Visiting is encouraged and it was clear from speaking with the Registered Manager that the home recognises the importance of visits from friends and family, and these are treated as special occasions for the Sisters. The Community provides an advocacy service, with 4 Community Sisters who can be called upon to advocate on behalf of any of the Sisters living in the home. Where they are able, the Sisters are encouraged to maintain their independence, in the knowledge that staff are available to assist them should the need arise. Sisters spoken with said that they enjoy the food and there is always a choice available, which was evidenced by the records kept. The lunchtime meal was observed, and the Sisters were enjoying their meal, and staff were available to assist where necessary. A second dining area is used for those Sisters who are frail and in need of more assistance with their meals. The kitchen was clean and tidy and the records viewed were up to date and being maintained to a good standard. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure in place. There had been no complaints since the last inspection. The home follows the London Borough of Hillingdon Safeguarding Adults procedures. One adult protection case had been satisfactorily concluded since the last inspection. Staff have received updates in adult protection training. The Registered Manager said that she observes and discusses any practice issues with staff to maintain good care practices within the home. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 15 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, 20, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, thus providing a clean and homely environment for service users to live in. Several communal rooms are available, providing the service users with a choice. Equipment in the home is available to meet the service users needs, with evidence of ongoing assessment, thus ensuring any changing needs are identified and met. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The home is in the process of recruiting a maintenance person, and temporary cover has been provided to assist with keeping the maintenance records and repairs up to date. The Inspector carried out a tour of the home. The home is generally well maintained and there is a homely, peaceful atmosphere throughout. Some bedroom carpets are worn and in need of replacement. The Inspector and the Registered Manager discussed carrying out an up to date environmental audit, so that any areas requiring attention are identified and a programme of redecoration and refurbishment, with timescales for completion, Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 16 can be drawn up. The garden is well tended and there are areas for the Sisters to sit outside. The home has several sitting rooms available, plus two dining rooms. Areas have been provided to ensure that the Sisters can sit in comfort, and also to provide separate areas for those Sisters with additional needs, for example, dementia care or assistance with meals. All the beds in the home are electronic profiling beds. There are moving and handling aids to include a variety of hoists to meet the Sisters needs. Following a successful trial period, a new hoist has been ordered that meets the specific needs of one of the Sisters. There are sufficient assisted shower and bath facilities to meet the Sisters needs. There are rails in the corridors and grab rails are available in the assisted bath, shower and toilet facilities. The home was clean and tidy and smelled fresh throughout. The laundry room was being well managed and infection control information was on display. One washing machine has a sluice programme available. Clear laundering information and instructions were also displayed. Disinfecting hand gel was available for use throughout the home. Hand washing facilities are available in all areas where staff, Sisters and visitors may require to wash their hands. Separate sluice rooms with electronic disinfecting machines are available. Action is taken on an ongoing basis to identify and address any potential infection risks. The infection control procedures and practices in the home are of a good standard. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was appropriately staffed to meet the needs of the service users. Staff have received appropriate training to provide them with the skills and knowledge to meet the needs of the service users, thus maintaining good standards of care. Systems for vetting and recruitment practices are in place, however shortfalls identified could potentially place service users at risk. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the Sisters. The staffing rosters identify that staffing levels are being maintained and that cover is provided for any absences. Kitchen, laundry and domestic staff are employed in appropriate numbers to meet the needs of the home. A maintenance person is being recruited, and temporary cover has been put in place to keep the basic checks and repairs up to date. The majority of care staff are qualified to NVQ level 2 or 3 in care and there is an ongoing commitment by the home to offer all new staff NVQ in care training. The home has an induction programme, and on completion of this new staff commence NVQ in care training. The Responsible Individual stated that a new training programme to combine induction and foundation training, which meets the Skills for Care standards, is to be introduced in the near future. There is also evidence of staff attending training in topics relevant to the care of the Sisters. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 18 Five sets of staff employment records were viewed. Three contained all the required information, and there was evidence of an up to date application form in use. In one instance a Criminal Records Bureau check from another employer had been used at a time when this practice was no longer acceptable. In another instance the need to ascertain if the required procedure had been followed for a student placement at the home was discussed. The importance of ensuring that all checks are carried out correctly and due process is followed was discussed with the Registered Manager and the Administrator. The home has since contacted the Criminal Records Bureau for up to date information and advice. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 19 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home, and does so effectively. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Service users monies are well managed and securely stored. Systems for the management of health and safety throughout the home are generally good, thus safeguarding service users, staff and visitors. Shortfalls should be easily addressed. EVIDENCE: The Registered Manager is a first level registered nurse and she has completed the Registered Managers Award, NVQ 4 equivalent. She has attended training sessions relevant to the service user group and is aware of the need to keep Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 20 up to date with current practices. Staff spoken with said that the home is well managed and that the Registered Manager is supportive and approachable. The home has a system of auditing, to include service user plans, medications, falls/accidents and catering management. An environmental audit is also to be carried out. An annual satisfaction questionnaire is given to the Sisters to complete and the Registered Manager is aware to collate the results and forward a copy to the CSCI. Satisfaction questionnaires are also available near the signing in book for visitors to complete. The Responsible Individual has communicated with the CSCI and also spoke with the Inspector on the day of inspection. Policies and procedures have been updated and will be in place in the home by 01/08/06. The Registered Manager is aware that staff need to read and understand all new and updated policies and procedures relevant to their work at the home. There are clear systems in place for the management of individual monies. A record of all income and expenditure is maintained. There is evidence of regular audits being carried out to check the amounts held tally with the records maintained. Secure facilities are provided for holding monies. In some instances where funds have built up, the possibility of looking at ways for the Sisters to use their money whilst maintaining the religious observances of the congregation was discussed. The Registered Manager said that staff are up to date with mandatory training. Recent moving & handling update training had taken place, and fire safety training updates are planned for August 2006. Staff underwent infection control training this year. Five staff have attended a four day First Aid course, and the Registered Manager said that updates for staff who are appointed persons for emergency aid, plus food safety updates are being arranged. Risk assessments for equipment and safe working practices were in place, and there was evidence of new assessments being carried out for any newly identified risks. The fire risk assessment was not available at the time of inspection, and a copy has since been forwarded to the CSCI. The Fire Log book evidenced required checks of fire equipment and systems being carried out and recorded. The emergency lighting throughout the building had recently been replaced. Fire drills had not always been carried out at the required intervals, and this was to be addressed. Information provided by the Registered Manager showed that the servicing of equipment and systems was up to date. Water temperatures and tests for Legionella control had been carried out regularly and the results recorded, to include any adjustments made to maintain water temperatures to the required safe temperatures. The home has an up to date comprehensive Health & Safety procedures manual in place. COSHH, safety data and prevention of accidents information was on display in the home. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 22 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 OP4 Regulation 12 Requirement An application for a variation to the conditions of registration must be submitted to the CSCI in respect of those service users with a diagnosis of dementia. Correction fluid must never be used on legal documents, to include service user plans. Bedrail assessments must clearly identify the safety and appropriateness of the use of bedrails in each individual instance. (previous timescale 31/03/06 not met) All medication receipts must be fully checked. Where a medication has not been correctly dispensed, this must be addressed with the dispensing pharmacist. All liquid medications must be dated when opened. Full dosage instructions must be included on the MAR for all medications. A full environmental audit must be carried out and a programme of redecoration and refurbishment with timescales DS0000010934.V300086.R01.S.doc Timescale for action 01/08/06 2. 3. OP7 OP8 17 13(4)(7) 06/07/06 01/08/06 4. OP9 13(2) 06/07/06 5. 6. 7. OP9 OP9 OP19 13(2) 13(2) 23(b)(d) 06/07/06 06/07/06 01/09/06 Marian House Version 5.2 Page 23 8. OP29 19 9. OP38 23(4) for completion then formulated. All required employment procedures, to include obtaining Criminal Records Bureau checks must be followed for all new staff. Fire drills must be carried out at the required intervals of 3 monthly for all night staff and 6 monthly for all day staff. 06/07/06 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. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations It is strongly recommended that where hand written entries are made on the MAR, two registered nurses should check and sign for each entry. It is strongly recommended that the room temperature in the clinic room be recorded daily and if it is being recorded as above 25° centigrade, then remedial action must be taken to address this. Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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. Extracts may not be used or reproduced without the express permission of CSCI Marian House DS0000010934.V300086.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!