Inspection on 16/05/06 for Marie Louise House

This inspection was carried out on 16th May 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

Marie Louise House 11/07/08

Marie Louise House 12/07/07

Marie Louise House 10/01/06

Marie Louise House 09/08/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Marie Louise House Newton Lane Romsey Hampshire SO51 8GZ Lead Inspector Tracey Box Unannounced Inspection 16th May 2006 10:00 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 Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marie Louise House Address Newton Lane Romsey Hampshire SO51 8GZ 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) 01794 521224 01794 526310 The Hospital Management Trust To Be Confirmed Care Home 46 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (46), Physical disability (10), Physical disability over 65 years of age (10), Terminally ill (5), Terminally ill over 65 years of age (5) Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be over the age of 60 years. Date of last inspection 10th January 2006 Brief Description of the Service: Marie Louise House is a home for 46 service users situated in Romsey. The home is owned by the Daughters of Wisdom and leased to a registered charity, the Hospital Management Trust. The home has been built on the site that was previously occupied by La Sagesse school. The building has been designed to provide the service users with single en-suite accommodation and has been decorated and furnished to a very high standard. The gardens have been landscaped and provide areas of privacy for service users to sit. The home places emphasis on the pastoral care that is provided by the Daughters of Wisdom who live in the convent alongside the home. Service users of all denominations are accommodated in the home. The home has a large car parking area and is within walking distance of Romsey town centre. The manager confirmed in the pre inspection questionnaire that the home charge weekly fee of between £685 and £830 per resident. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was carried out over two days by two inspectors. The inspectors toured the home, looked at records, care plans, policies and procedures and resident’s finances and witnessed medication being administered. The people living at Marie Louise House prefer to be referred to as residents, therefore the rest of this report will reflect this. The inspectors witnessed lunch being eaten and positive interaction between residents and staff as they participated in daily activities such as watching films as planned by residents and the activities coordinator. The inspectors had the opportunity to speak with residents and a visitor to the home. The inspectors also spoke to four members of staff. The home was clean and provided pleasant accommodation for residents. What the service does well: What has improved since the last inspection? The home have improved activities that are flexible and varied to meet the residents’ expectations and preferences. The manager has reviewed the homes complaints procedure which specifies how complaints may be made and who will deal with them within the stated timescale. The duty roster shows the names of the staff that have actually worked. The pre admission format has been improved to provide a comprehensive assessment tool. The manager said the general atmosphere of the home has improved, providing a homely environment. Staff feel that they are working better as a team. Resident and staff meetings have become more regular and are well attended, one relative confirmed either she or her siblings attend relatives meetings, which they find very useful. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 6 Security at the main entrance to the home has improved, there is a door entry system in place for ‘out of office’ hours, a television monitor shows staff who is trying to gain access to the home, a door entry code for staff to gain access is changed on a regular basis. 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. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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 Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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): 1,3 & 6 Prospective residents receive information about the home that will enable them to make an informed choice. The home have a comprehensive pre admission assessment form which enables each resident to be fully assessed to ensure the service users needs can be fully met by the home. 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. EVIDENCE: The manager has revised the home’s statement of purpose, which sets out the aims and objectives of the home and includes a service user’s guide providing basic information about the service to existing and prospective residents. One resident confirmed they had received a copy. The inspector asked the manager to remove the word ‘registered’ prior to manager when referring to herself, as she is not yet registered with the CSCI as manager. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 9 The pre admission form has been greatly improved, the manager or the deputy complete these assessments, which they say are easy to follow and more comprehensive. It was suggested that a space is available on the form for a signature of any other people who are providing information for the assessment. The manager agreed and said this would be added. The home does not provide intermediate care. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Care plans do not reflect the individual health, personal & social needs of resident’s to ensure their personal needs are met. Residents are protected from the homes medication policies & procedures. Residents feel they are treated with dignity and respect & that they are given information to enable choice. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were in place for all the residents but these were not detailed or personalised to address the individual care needs of each resident. The care plans were “core care plans” which staff had completed by ticking a box in each section of the plan. There was a section at the bottom of each plan for additional information; all these had been left blank. None of the records seen by the inspectors contained a care plan for night care/sleeping. All the records contained a form to be signed by the resident or their representative to say they had been involved in the care planning process. All these forms had been left blank. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 11 At the last inspection the inspector was informed by the new manager that they were aware of the unsatisfactory documentation of care plans in the home and had already identified this as a priority to be addressed as part of her management strategy plan. The inspector was also informed that the care planning for the home was shortly to be documented on a computer and that the care plans at that time were just temporary. No progress appears to have been made with the care plans and the same requirement made at the last two inspections has not been. It is of serious concern that care plans are not being updated or have in depth information within them to enable staff to competently attend to residents needs effectively. This has been required on two consecutive occasions, 30/09/05 and 01/03/06. This matter will now be addressed by way of a serious concern letter outside of this inspection report. One Inspector sampled risk assessments for the building, which were comprehensive and included risk assessments for activities and staff. Policies and procedures are available regarding health and personal care, staff were aware of where to find policies should they need to refer to them. The manager confirmed in the homes pre inspection questionnaire that the policies were reviewed in May 2006. The inspectors witnessed medication being administered by a trained RGN (Registered General nurse.) The recording procedures were found to be correct, and the staff member said she received regular monitoring by the deputy manager, as well as training in administration of medication, however certificates were not available to confirm this. All the residents spoken to stated that they were well cared for and treated with respect and their dignity is upheld by the staff. One relative said “staff are always helpful and respectful of my mother”. Staff said they are aware of the importance of dignity and respect, one staff said “ I treat people as I wish to be treated, and I respect my elders”. The manager confirmed staff receive training to ensure residents feel that they are treated with dignity and respect and that residents views are listened to and respected, however certificates were not available to confirm this. The recent questionnaire stated residents feel that they receive information which enables them to make choices. The manager confirmed in the homes pre inspection questionnaire that policies and procedures are reviewed and available for staff to access regarding residents health and personal care, and that residents access the district nurse and audiologist via their Doctor. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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 & 15. Residents social, cultural and religious needs are met and they are able to participate in a programme of suitable activities, receive visitors as they wish and are offered a choice of nourishing well-presented meals served in a relaxed atmosphere. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The receptionist has taken on responsibility as activities coordinator during the afternoons Monday-Friday, and schedules activities for residents to participate in over the weekends. The manager explained the home have a separate budget for residents activities. The inspector sampled records which show the activity that has taken place, and what each resident thought about it. The home have an activities committee, nine residents and staff have been arranging a summer fair. The inspectors observed residents eating lunch in the dining room, the atmosphere was relaxed, residents were offered choices of main meal and desserts. The manager explained some residents choose to eat their meals in their bedrooms, the manager explained the way meals are distributed to residents in their rooms has been improved, to ensure the meals are hot and Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 13 are served to the resident in their room, and not plated up in the kitchen. Cold drinks, tea and coffee with biscuits and cake were available throughout the day and staff are able to access the kitchen at night to provide hot drinks and snacks for residents who wish them. Residents spoken with said that they were able to exercise choice over their daily living activities. The registered manager said that there were no residents from an ethnic minority at present but that if a resident had cultural or religious interests every effort would be made to accommodate them. A Church of England service is held every day, and Pastoral sisters visit daily and speak with residents if they wish. Residents are able to choose to attend the services as they wish. The home has an open visiting policy. This was evidenced by records of visitors to the home and confirmed by relatives and one relative, who confirmed they visit at different times of the day and are always welcomed. The manager confirmed in the homes pre inspection questionnaire that policies and procedures are in place to ensure residents are supported to lead active lives as they prefer, however care plans did not reflect this. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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 & 18. The home has a satisfactory complaints procedure, which residents feel able to use and an adult protection procedure to safeguard residents from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to were aware of whom to complain to, should they have a need to, although at present they were happy with the care they receive. The homes complaint log was looked at and showed adequate details of the complaints received and that they had been resolved. The complaints procedure in the policy and procedure file was different to the complaints procedure held in the ‘service users guide’, the manager said this would be amended so that both documents hold the same relevant information. One staff said ‘I am aware that reporting any concerns or complaints is important to improve things, I know that I should speak with the matron, or the owner if it is about the manager.’’I have received training in Adult Protection issues.’ The home have included the corporate Hampshire County Council and adult protection procedure, which includes a whistle blowing policy. The manager confirmed in the homes pre inspection questionnaire that policies and procedures are reviewed and available for staff to access regarding complaints and protection, and that staff receive training in Adult protection, however training records were not available to support this. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 15 Three residents handle their own financial affairs, the home store their money and corresponding records safely. One inspector looked at these records and they were found to be correct records of the money held. The manager confirmed residents can access their money during office hours, Monday to Friday, so forward planning is needed to ensure residents have enough money for the weekend. The manager said relatives send money to the resident as and when they need it, the home safeguard the money until it is needed. One resident said ‘if I need any money I get it, I sign to say how much I have received, and another member of staff confirms this amount.’ Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. The environment provides service users with a warm and comfortable home. There is a good infection control procedure at the home to safeguard the welfare of service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was opened approximately one year ago, it is very pleasant, and clean. The main entrance has a reception area with a receptionist, care staff ensure the security of this area out of office hours. The home has security cameras to the outside of the home, which can be seen on screens in the nursing station areas on each floor. Residents spoken to were complimentary about their rooms and confirmed that it met their needs. Bedrooms were personalised and it was evident that service users are encouraged to bring into the home items of personal belongings. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 17 The home have contractors to ensure the maintenance of systems within the home. The home have recently changed the contractor who maintains the garden. The home is reviewing its laundry facilities, at present the one washing machine and one tumble dryer are not sufficient for the volume of washing. The manager explained the home have recently started to send bed sheets to a contracting company, this has reduced the work load for staff. The manager said the laundry is staffed by one member of staff every day, which is sufficient for the home. The manager has devised daily cleaning schedules which staff sign once completed. The policy on infection control practices was in place. Staff were seen to observe these and used different coloured aprons for providing nursing/ personal care. Gloves were available and procedures for dealing with infected materials were in place. The manager confirmed in the homes pre inspection questionnaire that all staff have received training on infection control issues, one staff member said that they have received training on infection control and the control of substances hazardous to health (COSHH), four certificates confirmed that domestic and kitchen staff had received training. All parts of the home visited on the day were clean and there were no adverse odours in the home. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. There is a stable staff team ensuring that residents are supported, however records were not available to show that staff were skilled to meet individual resident’s needs. The recruitment procedure for the home ensures the vulnerable people living in the home are protected. Staff appear to be trained and competent to do their jobs, however records do not show this. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota has been improved to include the actual hours that staff work. The manager explained the home have adequate staff on duty to meet the residents needs, the home currently has 5 staff vacancies, these hours are covered by existing staff working additional hours, or the home use one agency who provide care staff, the manager said this ensures continuity of care for residents. The manager has devised a new training record, once completed this will show what training staff have had, and when they need to renew it. The manager explained at present the home has 29 of its workforce either working towards, or have achieved National Vocational Qualification (NVQ) levels 2 and 3. The manager will look into whether the RGN’s qualification is equivalent to an NVQ level 3, this would increase the total staff with NVQ qualifications to over 50 . Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 19 The inspector sampled records of the fire drill log, which shows un announced fire drills occur regularly, all records of fire alarm and equipment were satisfactory. The manager explained staff have received adequate training, and three staff said they had received appropriate training to enable them to carry out their role correctly, which included staff watching training videos, however no records or certificates were available to show that staff have attended mandatory training in health & safety, moving & handling, first aid, fire safety, infection control and food hygiene, or any specialist training to ensure the residents individual needs are met. The inspector saw four certificates that showed staff had attended COSHH training recently. Therefore a requirement was made for the manager to ensure staff working in the home must receive training appropriate to the work they are to perform, certificates must be available to confirm this The inspector examined copies of four staff recruitment records. These were all found to be in order. There was evidence that written references had been obtained, application forms had been completed and evidence of personal identification was available. Appropriate checks had been undertaken with the Criminal Records Bureau and the Protection of Vulnerable Adults register. Work permits had been obtained from the Home office where necessary. The manager showed the inspectors a comprehensive daily routine guidance list which will be given to new and agency staff to help them during their shifts. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38. Service users feel the home is managed well, the manager is following the process to apply to the CSCI as registered manager. The home’s procedure for dealing with residents’ finances is good and safeguards residents interests. The procedures and practices for the health and safety of residents and staff are good Resident’s and staff’s health, safety and welfare are not fully protected by the home’s practices. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 21 The manager is not registered with the CSCI, however she has started the application process. The manager explained she will be commencing her Registered Managers Award (RMA) in September 2006. The manager is a member of the Partnership in Care Training (PACT) and is commencing a Dementia train the trainer course arranged by Hampshire County Council. The management structure is clearly defined in the homes statement of purpose, staff spoken with said the manager and deputy are very approachable. One relative said they find the manager easy to talk. The provider visits the home to conduct an un announced audit of the home under regulation 26 of the Care Standards Act 2000. The inspectors read the results of a satisfaction survey which was distributed to residents and staff at the beginning of this year, overall the findings were very positive. The manager said she has arranged meetings with relatives, to date two have occurred, the response was positive, one relative confirmed they found the meeting useful, and will attend in the future. Staff said they attend regular staff meetings which include one separate meeting for trained nurses and care staff , and one joint general meeting for all staff. The manager explained a full time administrator deals with any money which is held in the home on the residents behalf. Money is kept secure in a safe. Residents have agreed to the fact that they can only access their money during office hours. The inspector looked at financial records for two residents money which is stored by the home, they showed that receipts and invoices for all transactions entered on behalf of residents are kept, the amount of money stored matched the balance as shown in the records The manager explained she sees staff on an individual basis as and when they require, however there is no formal supervision process, therefore the manager is required to ensure staff receive structured supervision by an appropriately trained line manager. The manager said she will shortly be conducting staffs’ annual appraisals. The inspector sampled the accident reporting records which were very comprehensive. The storage of these records needs to be revised, as all records are currently stored together. Staff said they follow policies regarding health and safety, however, Staff training files were not available to show that they had received training in health and safety, first aid, food hygiene, fire awareness or moving and handling. The manager explained certificates have been issued, however they were not available for the inspectors to see. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 22 The home has adequate risk assessments for the building. The inspector witnessed good food hygiene techniques in the serving of the lunch, however certificates were not available to show that staff had received up to date training. All materials that may be dangerous to health were stored appropriately. Radiators were covered and had thermostatic controls. A sample of the servicing records was seen. The manager said that there is a rolling programme for the servicing of equipment that is contracted out to external agencies. Staffs confirmed their awareness of health and safety procedures, and were to find them. The fire log was inspected and the records indicated that the fire safety equipment had been tested and serviced within the guidelines. A fire risk assessment was in place and had been completed recently. There was evidence of regular staff fire training. The manager confirmed in the homes pre inspection questionnaire that all servicing is carried out when needed, and that staff receive adequate training in health and safety, also policies and procedures have been reviewed recently. Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? 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 manager, in consultation with the resident must set out in writing as to how the needs in respect of health and welfare of the resident are to be met. This is a repeat requirement from the last 2 inspections. Timescales of 30/9/05 and 01/03/06 were not met. The manager must ensure staff working in the home must receive training appropriate to the work they are to perform, certificates must be available to confirm this. The manager must ensure staff working in the home must receive training appropriate to the work they are to perform, certificates must be available to confirm this. The manager must ensure staff working in the home must receive training appropriate to the work they are to perform, certificates must be available to confirm this. The manager must ensure staff working in the home must DS0000062154.V288741.R01.S.doc Timescale for action 18/07/06 2. OP38 18(1,c,i) 30/06/06 3. OP27 18(1,c,i) 30/06/06 4. OP30 18(1,c,i) 30/06/06 5. OP28 18(1,c,i) 30/06/06 Marie Louise House Version 5.1 Page 25 6. OP36 18(2) receive training appropriate to the work they are to perform, certificates must be available to confirm this. The manager must ensure staff receive formal supervision by an appropriately trained line manager 18/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Marie Louise House DS0000062154.V288741.R01.S.doc Version 5.1 Page 27 - 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. 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