Inspection on 31/10/05 for Marina Rest Home

This inspection was carried out on 31st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Marina Rest Home 30/07/09

Marina Rest Home 06/08/08

Marina Rest Home 29/08/07

Marina Rest Home 01/08/06

Marina Rest Home 27/06/05

Marina Rest Home 17/02/05

Marina Rest Home 22/09/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Marina Rest Home St. Cuthbert Street Hebburn Tyne And Wear NE31 1DJ Lead Inspector Sharon McDowell Unannounced Inspection 31st October 2005 09:30 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 Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 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. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marina Rest Home Address St. Cuthbert Street Hebburn Tyne And Wear NE31 1DJ 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) 0191 483 5588 NO FAX Dr Inder Paul Vinayak Dr Veena Vinayak Mrs Heather Anne Pirie Care Home 44 Category(ies) of Dementia - over 65 years of age (17), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (28) Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: The Marina Rest Home is a 44 bedded care home providing personal care for older people, some of whom may have dementia. The home does not provide nursing care. It is located close to the town centre, and high street shops in Hebburn are a short walk away. There are also good local bus links nearby and ample car parking in the grounds of the home. The home is a two-storey converted property which comprises of two separate units; including one smaller 17 bedded unit for people with dementia. There is level access to the front of the building into a lobbyway before entering the main lounge. A passenger lift enables access to and from the first floor. Although the home has double rooms these are used as spacious singles. None of the rooms have en-suite provision but adequate supply of toilets and bathrooms are located throughout the building. Externally, to the front there is a garden area which provides seating for residents. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on the 31st October 2005 over one day however, due to technical problems with CSCI IT systems the original report was lost and could not be sent to the provider. A second visit took place by the Regulation Manager to follow up and check out issues before a further report could be written. A sample of records was looked at including: care plans, risk assessments, staff files, residents monies and policies and procedures. What the service does well: What has improved since the last inspection? The home has continued to improve in many areas and has met most of the requirements made at the last inspection. Care plans and the recording of risks are greatly improved, and staff are more confident about how they use these. An activities officer is now employed at the home which means that service users can have the opportunity to take part in structured activities, if they want to. A programme of activities is displayed in the home and staff tell residents about what is planned to help them make choices. The manager has encouraged staff to access a lot of training which improves staff knowledge and skills in many areas. For example: looking after people who have dementia, safeguarding vulnerable adults, medication and health and safety. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 6 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. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 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 Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 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): 1,2, & 5. Standard 6 is not provided by the home. Satisfactory information is available for residents and their families to help them make an informed choice prior to admission to the home. EVIDENCE: The Statement of Purpose and Service User Guide were updated in January 2005 to make it more user friendly and provide useful information to help residents make an informed choice before moving into the home. Both documents provide information about some diversity issues such as religious/spiritual needs of residents and the services available but don’t currently explore other cultural issues. Pre-admission visits to the home are available to prospective residents and their relatives, and no restriction is placed on the time this is available. Residents are welcome to call at mealtimes to share a meal or have a trial stay if they prefer, before making their final decision. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 9 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): 7,9,& 10 Care plans continue to improve and demonstrate the involvement of residents in planning their care. Case files are more comprehensive and provide an ordered structure to easily locate information. Clear procedures and good training for staff help to ensure that medication practice is safe and protects residents from the risks of harm. Residents feel they are treated with respect and dignity by all staff. EVIDENCE: The staff have worked hard to improve the overall standard of assessment and care planning with individuals. They are regularly reviewed and discussed with residents and /or their families. A good range of assessment information is available which highlights a range of needs and informs the care plan. Risk assessments are also continuing to develop around any restrictions placed on individuals as a result of their care needs. The home uses a monitored dosage system which minimises the risk of drug errors. All senior staff have received accredited medication training, as well as Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 10 one member of the care team who provides senior cover during holidays etc. This has been supplemented by additional training from the suppliers of the monitored dosage system to ensure all senior staff are competent in the use of this system. And the manager is currently arranging for 3 care staff to undertake a safer handling of medication course. Storage of medications has improved by using a metal cupboard for the storage of CD drugs. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 11 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): 14 Residents continue to have control over their lives and are encouraged by staff to maintain their independence. EVIDENCE: An activities officer is in post to help plan and co-ordinate a range of activities and explore interests with residents on an individual and group basis. This has ranged from singers/performers visiting the service, to parties for special occasions, to trips out of the home. The activities officer has attended some training and consulted with the Alzheimers Disease Society for ideas about different activities and how to record what happens. Residents also maintain local links and independence by accessing shops and other facilities in the local area, independently where they are able. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 12 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): 17 Robust systems are in place to ensure that resident’s legal rights are protected. EVIDENCE: All residents are encouraged to continue to take part in voting and other civic processes, either by postal vote or visiting the pole station to vote in person, where they are able. While there are no residents currently using advocacy services, the manager and deputy have accessed these in the past and know how to access these services. Where restrictions are placed upon individual’s lifestyle, this is recorded in the care plan and risk assessment documentation to reflect any agreement reached Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 13 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): 21 & 26 The home is clean and decorated to a good standard. However, maintenance is not always attended to as quickly as it should be which affects the availability of facilities to residents. EVIDENCE: Much work to upgrade the décor and overall state of the building has continued since the last inspection, making the environment comfortable for those people living there. While sufficient toilet facilities are provided in the home, they are not all fully accessible to people who may rely on walking aids are wheelchairs to get about. The main accessible toilet/shower area located on the ground floor was out of order during the visit and was reported to be out of order for a few days. This type of toilet has proved to be expensive and difficult to repair, making it difficult to repair quickly. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 14 Residents with walking difficulties were then observed having some difficulty negotiating the other available toilets with their walking aids, despite help from staff. The layout of one toilet has been changed at some point leaving the soil stack pipe to run along the ground and take up part of the available space for turning. The toilet is not positioned effectively to make access easy and the manager was advised to seek advice from the Council’s access officer or an occupational therapist to improve the layout. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 15 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): While there is a stable staff team in place with little turnover, robust recruitment procedures are in place when new staff are recruited, to ensure the safety of residents is protected. They also recognise the need to monitor diversity but this is not yet fully developed. Staff are employed in sufficient numbers to ensure the safety of residents is not compromised. EVIDENCE: The majority of staff at the home have worked there for a long time and both residents and staff feel comfortable with each. This has helped to create a ready rapport where staff know and understand resident’s needs well. Residents are confident to approach staff and staff are responsive in dealing with requests. Recruitment systems take account of culture and diversity and all application packs include an equal opportunities monitoring form. However, while this information is collected, it is not used as part of the QA or recruitment systems either to provide statistical data or to inform changes in recruitment practice i.e. positive discrimination where there is under representation from specific groups. Appropriate and necessary checks are undertaken including CRB and professional references. In addition, if staff leave, staff complete a notification of resignation form and an exit interview is carried out. This helps to inform the quality assurance process. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 16 The manager understands the importance of ensuring that appropriate numbers of staff are always on duty and this is reflected in staffing rota’s and any cover arrangements made during absence, holidays etc. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 17 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, 32, 34, 35, 36 & 38 The manager has an open and approachable manner and welcomes contact with residents and their relatives. She is accessible, confident in her role and supports her staff team to deliver an effective service. The home is run in the best interests of the residents and their rights, interests and welfare is safeguarded by a well trained and responsive team. Residents finances are well managed and recorded, with a clear audit trail of expenditure. The health and safety of residents and staff is seen as paramount in the home and appropriate procedures are in place. EVIDENCE: Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 18 Residents said they are comfortable and happy in the home, and that their relatives can visit and enjoy a meal with them. They also felt that the staff team and the manager are approachable and know them well. Records show that staff receive regular supervision every 8 weeks and guidance from the management team in the home. Staff complete a selfassessment of performance and this is explored with them during the supervision session. However, sessions focus mostly on performance, which good, but does not demonstrate the developmental work that the manager promotes with all staff. Some discussion took place about how this could be further developed. Residents finances are clearly documented and kept separately. Regular audits are undertaken by the manager and deputy to help safeguard residents finances. However, following the introduction of ‘chip and pin’, it has been necessary to introduce a post office account to deal with residents ‘personal allowance’ only. Safe keeping facilities are in place and residents monies are kept separately within individual wallets. The health and safety of residents and staff are seen as paramount within the home, and the manager has accessed in-depth training for staff. This includes: infection control, risk assessment, first aid, moving and handling, fire safety and accident reporting. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 19 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 3 X X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 2 X 2 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X 3 3 3 3 3 Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 20 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 2 Standard OP19 OP27 Regulation 23 23 Requirement Repair ‘Saniflow’ toilet in accessible shower room. The provision of maintenance services must meet the needs of the home. (OUSTANDING SINCE JUNE 2005) Timescale for action 31/03/06 31/03/06 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 Refer to Standard OP22 OP29 OP36 Good Practice Recommendations Approach the Council’s access officer or occupational therapist for advice on more accessible layout of toilet facilities. Collate and review information collected as part of Equal Opportunities monitoring during recruitment to inform equality and recruitment processes. Supervision should reflect the developmental needs of staff. Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Marina Rest Home DS0000000236.V253847.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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