Inspection on 24/10/06 for Marian House Nursing Home

This inspection was carried out on 24th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marian House Nursing Home 20/08/07

Marian House Nursing Home 06/01/06

Marian House Nursing Home 01/06/05

Marian House Nursing Home 18/11/04

Marian House Nursing Home 25/05/04

Marian House Nursing Home 25/02/04

Marian House Nursing Home 28/08/03

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

CARE HOMES FOR OLDER PEOPLE Marian House Nursing Home 32 Walmley Ash Road Walmley Sutton Coldfield West Midlands B76 1JA Lead Inspector Ann Farrell Key Unannounced Inspection 24th October 2006 08:00 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 Nursing Home DS0000024866.V317140.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 Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marian House Nursing Home Address 32 Walmley Ash Road Walmley Sutton Coldfield West Midlands B76 1JA 0121 240 8000 0121 240 8039 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) Walmley Care Home Limited Miss Josephine Louise Stinton Care Home 41 Category(ies) of Physical disability (35), Physical disability over registration, with number 65 years of age (35) of places Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 41 places - over 50 years general nursing care for physically disabled service users where disablement began before pensionable age. That the home can accommodate 1 named service user under 50 years old for general nursing care for reasons of physical disability. 6th January 2006 Date of last inspection Brief Description of the Service: Marian House Nursing Home is a private home owned by Walmsley Care Homes Limited, and provides nursing care for up to 41 older people. It is also able to offer care to adults over 50 years of age with a physical disability. Marian House is a purpose built home with single accommodation on both floors, many of which have en suite facilities. There are also ample assisted bathing and toilet facilities that are fully accessible by residents in wheelchairs. There are lounge/dining areas situated on both floors. There is a range of aids and adaptations designed to accommodate residents with limited mobility, such as hoists, grab rails, a passenger lift and nurse call system. The home is situated in a residential area and there is easy access to public transport. There is adequate parking to the front and side of the property and a well maintained garden to the rear, which can be used when the weather permits. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork inspection was conducted over two days commencing at 8.00 am on 24th October 2006. This was the first statutory inspection for 2005/2006. The managers were present during the inspection. During the inspection process the inspector undertook a tour of the home, sampled residents files and other documentation. Case tracking was used in respect of some resident’s files to determine care from the time of admission to the home plus direct and indirect observation were used to determine practice. Prior to the fieldwork a pre inspection questionnaire was sent to the home to assist the process and this was returned. During the fieldwork the managers, five members of staff, six residents and two relatives were spoken to. What the service does well: Marian House continues to provide a very pleasant, clean and well maintained environment for residents. Residents’ rooms were comfortable and homely and a large number of them have en-suite facilities. The home has a friendly and relaxed atmosphere. Staff are very welcoming and ensure residents privacy and dignity is maintained at all times. There are flexible routines; no rigid rules. There is a professional effective management team and good management systems in place. There is a range of on going training for all staff to provide them with the skills and knowledge required to meet resident’s needs. Residents who spoke with the inspector stated the staff were good; they enjoyed the food and special diets are catered for. Relatives reported favourably on life in the home, and were happy with the service provided. One relative stated “I am thankful mum is here”. Another stated, “It is like home, staff are pleasant and make you feel welcome, they ring the doctor and keep you informed. I feel we are working together”. The medication is of a generally good standard. The records in respect of assessment and care planning were of a good standard supporting staff in providing care for residents to meet their needs. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 6 There are regular meetings with residents and staff, there is an open culture enabling people to raise any concerns and the managers are willing to try new things. 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. Marian House Nursing Home DS0000024866.V317140.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 Nursing Home DS0000024866.V317140.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, 2, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose, service user guide and contract of residence require amending to ensure they are in line with the updated regulations and provide accurate information for prospective residents and their families to make an informed decision. Pre-admission assessment assessments for residents needs are undertaken enabling staff to determine if they are able to meet their needs following admission to the home. EVIDENCE: The home generally admits residents for long-term care. There is a statement of purpose and service user guide, which provides information for prospective residents, families and placing authorities. On inspection they were found to contain exactly the same information. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 9 The service user guide is satisfactory, but the contract of residence will need to be reviewed in light of the regulations that were updated in September 2006. The statement of purpose requires more detail and additional information. Guidance was provided to the manager to aid with the process of developing the document. A sample of care plans were inspected, which included pre-admission assessments. The assessments were found to be of a good standard and provided staff with appropriate information to develop a care plan for residents entering the home. To date staff have not confirmed in writing that they can meet prospective residents needs. This will need to be undertaken in order to comply with the regulations. Marian House Nursing Home DS0000024866.V317140.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 good. This judgement has been made using available evidence including a visit to this service. Care records were found to be comprehensive and reviewed regularly to assist with meeting resident’s needs. Medication was generally of a good standard; some further developments are required to ensure it is fully robust. More attention is required in respect of continence management, records of dressings and systems to ensure consistency in aspects of care. Observations of staff practices raised no concerns regarding the maintaining of residents’ privacy and dignity. EVIDENCE: Following admission to the home staff complete documentation and risk assessments prior to drawing up a care plan. Risk assessments had been completed in respect of tissue viability, nutrition, moving and handling and bed safety rails generally. Care plans are developed upon the information obtained at assessment and outlines how the resident’s needs are to be met by staff. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 11 On inspection of a sample of records they were found to be comprehensive and of a good standard. Reviews had been undertaken regularly, but changes had not consistently been included in the care plan. Staff must ensure that any changes to care must also be included in the care plan to ensure it is up to date as it is a working document. Daily records and records of professionals visited are maintained separately. It was not always clear that residents had the opportunity to see the chiropodist and dentist on a regular basis. On discussion with some residents they stated they saw the doctor and other health professionals when required. Staff must ensure these records are maintained to demonstrate appropriate interventions. Records in respect of aspects of care such as moving and handling, food charts, fluid charts, cream charts etc are retained in residents rooms to ensure staff have specific information available for them to undertake their role. Whilst touring the home there was a number of pressure relieving devices in use to reduce the risk of pressure sores plus moving and handling equipment to assist residents with mobility problems. However, there are only two hoists and there are a large number of residents who require hoisting. A supply of sliding sheets was found in bathrooms. These should be kept in individual residents rooms who requiring assistance with moving in bed to reduce the risk of cross infection. The management must review the current arrangements for moving and handling equipment and ensure there is adequate equipment in the home at all times to meet residents needs. Call bells are available in all areas, but were not always available to residents. On discussion with some residents they stated call bells were answered promptly. During the inspection there were times when the call bell was answered promptly, but on one occasion it was noted that a call bell had been answered and switched off with the member of staff stating they would return. However, the resident had to call again at a later time as the member of staff had failed to return. Some residents who experienced problems with verbal communication had been provided with communication aids. During the inspection it was noted that the home had only one size of continence pads, and this had been the case for a few days. A supply of various size pads was received on the second day of inspection. There was no evidence of continence assessments in resident’s files and some staff were not aware of the appropriate management of catheters etc. At the time of inspection some residents were waiting to use the toilet, but staff were busy dealing with other matters. The managers will need to review this aspect and ensure this area is addressed effectively. Some residents were being fed with feeding tubes; care plans and appropriate equipment were in place. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 12 It was noted that lemon and glycerine swabs were being used for mouth care. This was discussed with the managers as the swabs can cause drying of the mouth. During the course of the inspection they obtained further information and stated they would review practices. On discussion with some nurses there appeared to be some inconsistencies in practice when administering medication via feeding tubes. This are will need to be reviewed with staff to ensure consistent practices. Staff retain a separate file in relation to dressings required by residents. This was rather confusing, dressings were changed without any indication why and it appeared that some dressings were not renewed regularly. This area will need to be reviewed and records clearly demonstrate the size and type of wound, dressing required and indications for change in dressings. Residents were well presented, appeared relaxed and content. Staff were noted to respect residents dignity and privacy. All residents are registered with a local G.P. who visits the home when required. Staff liaise with the mutli-disciplinary health team as required and have set up a health promotion table to provide residents with more information about health living. Chronic disease management was discussed with the managers and they stated that they followed up various conditions arranging blood tests etc, but this was not observed in care records. It is recommended that aspects in relation to chronic disease management such as diabetes, asthma, and hypertension should be included in residents care records. The home’s medication is delivered on a monthly basis and is stored appropriately. On inspection it was found to be generally of a good standard. The medication for the monitored dosage system was good, but some of the audits for boxed medication were incorrect by one tablet, destroyed medication was not stored in a locked cupboard and at one stage the medication room and trolley were not locked and they were unattended. The home does not have any suction apparatus in case of emergency and this will need to be addressed. On discussion with resident’s they stated they were happy in the home and generally staff were good. Relatives stated, “It’s like a home, everyone is lovely, they ring the doctor if there are any problems and keep you informed. I feel we are working together”. Another relative stated, “ I am more than happy and am thankful that mum is here”. Marian House Nursing Home DS0000024866.V317140.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents felt able to exercise choices and there is a relaxed atmosphere. A variety of meals and special diets are catered for, however a range of fresh ingredients should be included in the meals. The range of activities needs to be developed considerable in order to provide residents with adequate stimulations. EVIDENCE: Routines are not rigid and there is a relaxed atmosphere on entering the home. The home has an open visiting policy and it was clear throughout the inspection that family members and friends visit the home and are made to feel welcome. A number of residents confirmed that they are encouraged to maintain links with community networks as they wish. One resident said, “I go to church locally, and also attend a luncheon club”. There is a well-maintained, mature garden to the rear of the property with patio area and seating, which provide a pleasant area for residents to sit when the weather permits. There are regular residents meetings and a representative from the residents, who is responsible for writing a monthly Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 14 newsletter. She stated she was visiting St Johns for lunch out and was waiting for the ring and ride service. It was stated an entertainer visits the home occasionally and a pantomime is organised for Christmas. During the inspection residents were observed reading, knitting, watching television and listening to the radio. On discussion with some residents they stated they did get bored and would appreciate more activities. One resident stated the hairdresser visits regularly and she receives communion every Sunday from the local church. A relative stated staff are very good, but they are busy and do not have time to sit and talk top residents. The manager acknowledged at the beginning of the inspection that this area needs to be developed. There are dining areas on each floor and residents have a choice where to take their meals. There are separate catering staff employed who cover all three males and there is a four-week rotating menu for meals with special diets and purée meals catered for. Residents are offered three full meals a day and their preferences are taken into consideration. The menu does not provide a choice at lunchtime, but it was stated alternatives were made available if residents preferred and staff ascertain any likes/dislikes on admission to the home. There is an option of meals at teatime and also the option of a cooked breakfast in the morning. Drinks are available between meals and a snack meal is available in the evening. At present the home uses mainly frozen vegetables, consideration must be given to using fresh ingredients to ensure that the food served is wholesome, balanced and nutritious to meet resident’s needs and preferences. All residents will not like frozen or tinned vegetables and will prefer fresh as they has a different taste, texture and appearance. The home retains a comprehensive record of food taken by residents who experience some problems. However, other records in the kitchen lacked detail and did not provide sufficient detail to determine whether the diet was sufficient to meet resident’s needs. This record is required by the regulations to demonstrate a varied nutritious diet. On discussion with residents they stated they enjoyed the meals. Some stated it could be hotter and it was noted that meals are not transported to the first floor in a hot trolley. Meal times were observed and meals appeared satisfactory, staff gave assistance where required and interacted with residents. Residents were offered a pre dinner drink that consisted of sherry or a sparking fruit drink. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure, “open” culture, role of Service User Representative, and good channels of communication all help ensure that residents views and opinions are sought and acted upon. EVIDENCE: There is a complaints procedure, which is displayed on the notice board. The Commission has not received any complaints about the home. They had received two formal complaints that had been investigated and records indicated they had been upheld. In addition, the home retains and record of informal complaints/concerns and it was noted that this had been used on a number of occasions indicating an open atmosphere and a willingness to address any issues. On discussion with residents and relatives they stated they did not have any complaints and if they did have any concerns they felt confident that staff would deal with them appropriately. The home has a policy/procedure in respect of prevention of abuse and it refers to the local multi-agency guidance. The whistle blowing policy will need to be updated with contact details of external organisations. There has been an allegation in the past year and the managers dealt with it appropriately. There was insufficient evidence and the allegation was not upheld. On discussion with staff about the procedure there was some variations in response suggesting that some staff are not fully conversant with procedures. This area will need to be addressed through training. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 home’s environment was clean, odour free and well maintained providing residents with a pleasant and comfortable environment to live. Practices in respect of infection control need to be more robust to reduce the risk of cross infection. EVIDENCE: The home is well maintained, clean and odour free. There are two lounges/dining rooms on the ground floor, which are pleasantly decorated and furnished providing a very pleasant area for residents to sit. There has recently been an extension of a further five en-suite bedrooms and a further lounge facility. There are a total of 41 single bedrooms and the majority of them have an ensuite toilet and wash hand basin. All rooms have recently been re-decorated and furnished to a good standard. All bedrooms have a call bell system, Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 17 lockable facilities, locks to doors, carpet/appropriate flooring, curtains and adequate lighting. They were noted to be homely and showing some degree of personalisation. There are assisted bathing facilities and toilets strategically placed around the home. It was sated that one of the baths was leaking and some of the toilets did not have tops to the cisterns. Bedrooms and communal areas are individually and naturally ventilated and windows are provided with restrainers for safety and security reasons. Radiators are of the low surface temperature type and the temperature of water from hot water taps was controlled to reduce the risk of scalding. There is a sluice facility on each floor, but there are no sluicing disinfectors. Currently staff clean out commode pots etc with a brush and soapy water. It was recommended that this procedure be reviewed until such time as disinfectors are fitted. On the second day of the inspection there was a large amount of linen etc to be laundered and some of it was on the floor in the laundry room. It was also noted that staff were using thin polythene gloves for dealing with incontinence. This is not appropriate and vinyl gloves should be used with latex gloves for blood spills. These are will need to be addressed in order to reduce the risk of cross infection. The kitchen is situated on the ground floor and is adequately equipped. On inspection it was noted that the following areas need to be addressed in respect of kitchen hygiene; • Some sauces had been opened and not dated with a use by date. • Decanted foods had not been dated. • Potatoes were stored on the floor. All foods items should be stored off the floor. • The potato peeler was broken. • Some of the knives need sharpening or replacing. • Some of the floor tiles were damaged and will need replacing. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be reviewed and adjusted, as there was not adequate staff on duty at times. There is a good recruitment process in place so safeguarding residents. Staff are provided with training providing them with the skills and knowledge to care for residents. EVIDENCE: The home has recently had an extension for a further five rooms and had admitted a number of new residents prior to the inspection. They were aiming to have seven care staff on duty in the morning with two nurses, but this was not being achieved regularly. Evening staffing levels were generally four carers and 2 nurses and overnight there is one nurse and two carers. During the inspection staff were noted to be busy and there were times when residents were not supervised. The staffing levels at the time of inspection were not adequate to meet resident’s needs. The manger stated they were actively recruiting staff and in some cases were waiting for recruitment checks to be completed. This is acknowledged, but alternative arrangements will need to be put in place until prospective members of staff commence duty e.g. agency or back staff. Catering, domestic, maintenance and administrative staff support care staff. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 19 A small sample of staff files were inspected and appear to be satisfactory; staff undergo a range of checks, which help safeguard residents. The home also employs overseas nurses who undertake adaptation training to work in this country as nurses. The Registered Manager is satisfied that the agency makes all necessary employment checks, and has received written confirmation from the agency to this effect. There is ongoing training in respect of NVQ and currently over 50 of care staff have completed it providing them with the skills and knowledge to care for residents. The manager has recently updated the induction training to ensure it meets the standards of the Social Skills Council. There was no indication the care staff had received copies of the code of practice or that copies of the NMC codes of practice for nurses were in the home. It is recommended that this be followed up. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective management team with good systems and an open culture. The health, safety and well being of residents are maintained and the home is run in the interests of residents. EVIDENCE: The Registered Manager is a qualified nurse with many years experience in managing a care home. A clinical manager and administrator support her and they appear professional and work well as the senior team. The management culture in the home is open, inclusive and receptive to new ideas. Regular meetings with residents and the role of Service User Representative continues to prove very constructive in ensuring that the views of residents are canvassed and acted upon. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 21 Copies of minutes from residents meetings indicated that they hope to start involving residents in the recruitment and induction process and this development is viewed in a positive light by both staff and residents. There are also regular staff meetings and minutes are maintained. On discussion with staff they were happy working in the home, confirmed that meetings and supervision occurred, but stated some of the nurses could be more supportive. There is a quality assurance system in operation, and the views of staff, residents, relatives and health professionals sought regularly, and feedback from interested parties informs practice in the home. The Registered Manager confirmed that the Registered Provider visits regularly. In keeping with the Care Homes Regulations it is necessary for the Registered Provider to visit the home at least once a month, to record the outcome of these visits, make the records available within the home and send a copy to the Commission. The home has a safe facility and do not generally hold any money or valuables for residents. Currently money is held for one resident and although there were receipts there were no records available to clearly demonstrate the transactions. In addition, records will need to be retained in respect of the residents fund. There was a good commitment to ongoing training for all staff, with individual training records. Training has included the mandatory areas such as fire, basic food hygiene, manual handling etc plus areas such as Tissue Viability, Abuse in the Care Home, diabetes, communication, hypertension etc. The home has undertaken servicing and maintenance in respect of much of the equipment. Areas that need to be addressed for health and safety include; • • • • • There was no record of water run from taps that are not used regularly in order to reduce the risk of legionella. There was no record of servicing pressure-relieving mattresses. It is recommended that the tissue viability nurse be contacted about this area. There was no record for the maintenance/checking of bed rails. There was no gas safety certificate for the cooker. Records of water temperatures checks indicated that baths are checked each month and taps approximately once in ten months. It is recommended that this be reviewed with the risk assessments. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 2 X X 2 Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4 Requirement Timescale for action 30/01/07 2 OP2 5 3 OP3 14 4 OP8 13(4) 12(1) The Registered Manager must ensure that the Statement of Purpose is reviewed and amended in line with the regulations. The registered person must 15/12/06 review the service user guide and contract of residency and ensure it is inline with the updated regulations. The registered person must write 30/11/06 to prospective residents confirming if they are able to meet their needs prior to admission to the home. 20/12/06 The registered person must ensure: • There is adequate manual handling equipment in the home to meet all residents’ needs to include hoists and sliding sheets. • A call bell is accessible to all residents to enable them to call for assistance. • Review the arrangements for answering call bells. • Suction apparatus is supplied. DS0000024866.V317140.R01.S.doc Version 5.2 Marian House Nursing Home Page 24 5 OP8 12(1) 14 17(1) 6 OP9 13(2) 7 OP12 16(2)(m) (n) 17(1) 8 OP15 16(2)(j) 17(2) 9 OP18 13(6) The registered person must ensure: • Suitable arrangements for the management of continence with assessment. • Suitable arrangements for dressings and records clearly indicate when they are changed, the dressing to be used, evaluations and changes of dressings. • A consistent approach to catheter care and PEG feed management. The registered person must ensure: • The accurate administration of all medication. • Destroyed medication is secured in a locked cupboard. • The medication door and trolley are kept locked when not attended by a member of staff. The registered person must ensure there is a suitable programme of activities/stimulation of residents and records are retained in the home. The registered person must: • Provide a range of fresh vegetables on a regular basis. • Ensure all meals are hot when served. • Maintain a record of food taken by all residents. The registered person must: • Ensure the whistle blowing policy is updated. • Ensure all staff are fully aware of the policies and procedures in relation to prevention of abuse and DS0000024866.V317140.R01.S.doc 30/01/07 30/11/06 30/01/07 20/12/06 30/12/06 Marian House Nursing Home Version 5.2 Page 25 10 OP19 16(2)(j) 11 OP21 23(2)© 12 13 OP26 OP26 13(3) 13 (3) 14 OP27 18(1) 15 OP33 26 (1) (3)(4)(5) 17(2) 16 OP35 the action to take in the event of an allegation. The registered person must ensure: • All sauces are dated when opened and stored appropriately. • Food items are not stored on the floor. • Decanted foods are dated with a use by date. • The potato peeler is repaired. • Knives are sharpened or replaced. • Damaged floor tiles are replaced. The registered person must: • Review the bathing facility and take any action required to ensure it is in working order. • Replace missing parts to toilet cisterns. The registered person must provide sluicing disinfectors in sluice rooms. The Registered Manager must ensure adequate precautions in respect of infection control to include the use of vinyl gloves for incontinence; latex gloves for blood spills and items for laundering must be placed in appropriate receptacles. The registered person must ensure there is adequate staff on duty at all times to meet residents needs. The Registered Provider must make available records of his visits to the home and forward a copy to the Commission. The registered person must ensure records are retained in respect of monies held on behalf of residents and the resident’s fund. DS0000024866.V317140.R01.S.doc 30/11/06 30/11/06 30/03/07 30/11/06 20/11/06 30/11/06 30/11/06 Marian House Nursing Home Version 5.2 Page 26 17 OP38 13(4) 17(2) The registered person must ensure: • Water is run from little used outlets on a regular basis and records are retained in the home. • A gas safety certificate is obtained for all gas appliances. • Bed safety rails are checked on a regular basis and records are retained in the home. • Review the arrangements and risk assessment for testing hot water temperatures. 20/12/06 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 3 4 5 Refer to Standard OP8 OP8 OP27 OP32 OP32 Good Practice Recommendations All health professionals’ visits must be clearly recorded on individual records. Details regarding the management of chronic diseases must be retained in resident’s individual files. It is recommended that all care staff be provided with codes of practice and copies of the NMC codes of practice are retained in the home. It is recommended that the manger review the current arrangements in respect of staff support and take any action required to address the issue. The tissue viability nurse is contacted regarding the servicing of pressure relieving mattresses. Marian House Nursing Home DS0000024866.V317140.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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