Inspection on 06/08/08 for Marina Rest Home

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Good service.

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 29/08/07

Marina Rest Home 01/08/06

Marina Rest Home 31/10/05

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Marina Rest Home Cuthbert Street Hebburn Tyne And Wear NE31 1DJ Lead Inspector Irene Bowater Key Unannounced Inspection 6th August 2008 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.V370082.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. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marina Rest Home Address 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 30 Category(ies) of Dementia (28), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (1), Old age, not falling within any other category (18) Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 18 Dementia - Code DE, maximum number of places: 28 Mental Disorder, excluding learning disability or dementia, over 65 years of age - Code MD(E), maximum number of places: 1 The maximum number of service users who can be accommodated is: 30 29th August 2007 2. Date of last inspection Brief Description of the Service: Marina Rest Home is a converted property to its present use as a care home. It comprises of two units, one caring for up to twenty-seven older persons and a separate seventeen-bed unit for people with dementia. The home does not provide nursing care. The older persons unit is two-storey, the first floor being accessed by a passenger lift or stairs. The Dementia Care Unit is a one storey newer extension. Each unit has lounges dining rooms bathrooms, bedrooms and toilets. Senior care staff and care staff, staff the home throughout the 24-hour period. The home is situated in a residential area close to the town centre. It is within walking distance of local amenities and accessible by local transport services. There is ample car parking space to the front of the building. The home charges £358:00 to £368.00p per week. Personal items such as clothing, toiletries, hairdressing and outings are not included in the fee rates. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 29 August 2007 and 5 June 2008. • How the service dealt with any complaints and concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and their relatives, staff and other professionals. The Visit: An unannounced visit was made on the 6th August 2008.The visit started at 09:15 and was completed at 15:15. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit. • We told the manager what we found. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. The care plans are person centred and show how people ate being supported to live their lives. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 6 Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. There are activities everyday should people want to join in. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. People said: “The meals are good” “We can have what we like” “I get plenty to eat” Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well being. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The home is clean, warm and comfortable. One person said: “I am still happy living here”. Visitors said: “I have no complaints or concerns X is happy”. “It’s a nice place and staff are good”. “I think its like a 5 star hotel”. What has improved since the last inspection? Day to day maintenance is being carried out. There are no odours in the home. Quality assurance systems are in place. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 7 Some new furniture as been provided in the communal areas and bedrooms. 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. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 8 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.V370082.R01.S.doc Version 5.2 Page 9 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): 3, Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information about the service and a comprehensive assessment of need before admission. This helps them make the right decision about using the service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose and Service User Guide, which is readily available. Reference is also made to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 10 Before anyone is admitted the registered manager or the deputy manager make sure that a full assessment is completed so that they can meet individual needs on admission. Should anyone be admitted by a care manager (through Local Authority) the staff make sure they receive a detailed assessment and care plan before the person is admitted. This information is then used to complete a plan of care for the individual living in the home. Before coming to live in the home people can come and visit and spend some time getting to know the home. Also the home confirms in writing to each individual that they can meet their needs and everyone has a contract that sets out the terms and conditions while living in the home. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 11 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. Access to health care is good and detailed care planning demonstrates that peoples’ needs are being fully met. EVIDENCE: Each person has a plan of care based on the admission information, which was carried out, by care managers and the home manager. Staff complete pressure sore risk, dependency, moving and handling, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools help the staff understand the level of risk each person and helps them complete a care plan. Care plans showed in detail how people’s needs were met. They were clear and detailed about previous lifestyle, likes and dislikes, health and social care. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 12 For example likes “crosswords,” “reading” “loved to travel” and “likes cats dogs and birds”. Other plans showed that some people dislike activities and joining in, preferring their own company or just chatting to staff. Care plans also set out how staff are to support individual preferences about personal care, daily routines and food preferences. Accidents are clearly recorded and where necessary this information is shared with other agencies. People living in the home have full access to all health services including, GP’s dental, ophthalmic and chiropody services. The home has good contact with district nursing services and asks the advice of specialist health care professionals such as dieticians and mental healthcare specialists when required. The home has policies and procedures to make sure staff administer all medicines safely. Records are in place for all medicines received, administered and disposed of. An audit of the Medicine Administration Records (M.A.R.) showed no gaps in recording. The home does not have any Controlled Drugs. The M.A.R. sheets do not have any personal identification of individuals so that errors in administrating medicines can be minimised. When handwriting directions on to the M.A.R. staff do not get a witness signature to make sure there has been no error. Also the medicine cupboard is very small, cramped and warm. The extractor fan was not working and staff were not recording room temperatures to make sure 25 C was not exceeded. Most of the staff have worked in the home for some time and know the people they care for well. All of the staff worked very hard to make sure everyone was treated with respect and their rights to privacy and dignity maintained. Marina Rest Home DS0000000236.V370082.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 good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are good, and mealtimes are organised. This makes sure people can lead full and active lives. EVIDENCE: The home benefits from an activities person who organises events on an individual and group basis. There is lots of evidence in both units of events that have taken place both in and out of the home. Although there is a designated person to plan leisure and social events the staff encourage and support people to take part in activities that they choose. Detailed records are kept of all activities and whether people enjoyed them or declined to join in. Events include in house entertainment, baking, music, board games and reading. There are photographs of past events displayed in the home. And Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 14 these include people enjoying trips to the beach, lunch at a local hotel and enjoying drinks in the garden. There are lots of pictures of the area “as it was” and some good memorabilia from the past which people enjoy talking about. Everyone has free access to listening to music, watching the television reading books, magazines and up to date daily newspapers. People are also able to access the very pleasant garden areas to the front of the home. Since the last visit to the home the home has reinstated the “open door” policy. There are regular communion services from the Roman Catholic Church and the Gospel Singers regularly visit the home. People are also supported to join in with their own Church Services should they wish to do so. Visitors are welcome at any time and are able to use the lounges or their relatives’ bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Information about advocacy is available in the home. Many have brought small items with them making their rooms homely and reflective of their previous lifestyles, religious beliefs or cultural backgrounds. There are dining rooms on each unit. Tables on both units were nicely set with appropriate crockery, cutlery and condiments. It is unfortunate that there are not enough tablecloths for all of the tables. The home’s menus are based on the known likes and dislikes of the people who live there. Daily menus are displayed in each unit. Menus are changes regularly and the cook talks to everyone to make sure they like what is on the menu. People said: “The food is good” “There is always plenty” “It’s a lovely dinner” Choices for lunch were roast chicken or meatballs with stuffing, Yorkshire pudding, potatoes, sprouts and cauliflower. Choices for dessert included rice pudding, yoghurts, fruit and ice cream. Juices and tea were available and some were able to self-serve. People were able to choose what they wanted at the point of service. And second helpings were offered and accepted. Drinks and snacks are readily available throughout the day. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 15 Meals are served from “hot locks” on both units. All of the food was nicely cooked, of ample portion size and well presented. Staff sat with people who needed assistance and help was given in a discreet sensitive manner. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place to ensure that people and their relatives are listened to and protected from abuse. EVIDENCE: The home has a complaints policy and procedure, which is easy to understand. It is in the Service User Guide and displayed in all areas of the home. The complaints book records all concerns with action and outcomes to prevent complaints from recurring. Since the site visit in August 2007 there have been three complaints. Two were resolved at home level and the third complaint resulting in a Safeguarding Alert that was dealt with following Local Authority procedures. Staff are trained in Safeguarding Adults procedures so can recognise abusive situations and would know what to do if they suspected abuse. There is also written information and guidance available in the home for staff to look at if they need further help. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 17 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): 19,20,21,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and safe but further investment is needed to create a more pleasing comfortable, place for people to live. EVIDENCE: The home has two units. The Southview Unit is the Dementia Care Unit and it is more modern and the furniture and fittings are still in a reasonable condition. Both the lounge and dining room were comfortably furnished. Attempts have been made to make the environment easier for people to manage. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 18 For example, bedroom doors have been painted in different colours have letterboxes and door knocks so that they resemble front doors. Names of people are on their doors with information of how they prefer to be known by. Pictures of old film stars and entertainers decorate the walls and there is a lot of information about the war years such as how to use dried egg for baking. There are lots of photographs of the old shipyards and a letter from someone about an air raid. This helps to provide reminiscent experiences, while at the same time providing an environment where people feel safe and secure. The boiler room on this unit is now kept locked and was clean and tidy. The Marina Unit has a large lounge and dining room downstairs with a separate lounge upstairs. New furniture and a large wide screen television has been provided from the Local Authority. While these areas including corridors are comfortable and clean there has been no redecoration or refurbishments for a number of years. Corridors, carpets and doorframes have been damaged from wheelchairs and constant use and are now looking worn and shabby. The designated smoking area has an overpowering odour of stale tobacco smoke, the walls are damaged, the radiator is not painted, the carpet is badly burnt and there are no curtains or light fittings. Many of the bedrooms have benefited from new furniture and fittings. People have brought small items with them making their rooms homely and reflective of their lifestyles. There is one large bedroom with an en-suite shower and toilet facility. Theses facilities are currently not working and need to be repaired as someone is coming to live in this room. There are at least two rooms, which are being used to store equipment, and records. The doors to these rooms need to be kept locked. Should there be any broken or unwanted items these need to be disposed of. There has been some water ingress to the ceiling in the upstairs lounge and further work is needed to repair the damage. The people living in the home do not use this room regularly. There are bathrooms shower rooms and toilets close to all communal areas and bedrooms. There is some damage to walls and floors and most of the areas would benefit from refurbishment. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 19 None of the bathrooms and shower rooms had bath thermometers so that staff could make sure the water did not exceed 43 C. The manager put this right at once. The laundry is very compact but is clean and organised. Liquid soap and paper towels are readily available for staff to use. Most of the areas do not have footoperated bins with lids to prevent spread of infection. On the day of the visit the home was clean and odour free. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: The home has two units, which are staffed separately. The Southview Unit has one senior carer and two carers during the day and the Marina has one senior carer and one carer during the day. Overnight there is one senior carer and two carers for both units. The registered manager is supernumerary and the deputy manager also has some supernumerary hours. In addition there are domestics, laundry, cook, kitchen assistants, and an activities person. The maintenance person is shared with the sister home. Staff files showed that a suitable application form had been used. Two references are obtained and Criminal Records checks are always carried out before anyone is employed. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 21 Training records show that over 50 of staff have a National Vocational Qualification. All staff have completed mandatory training. Other training includes equality and diversity, personal relationships and sexuality, dementia awareness, care planning, diabetes care including blood glucose monitoring, Infection control, safeguarding adults and palliative care. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a competent manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and is qualified and experienced to manager the home. Since the last visit in August 2007 quality assurance systems have been introduced. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 23 Audits of all care and other services are carried out with action and outcomes recorded. Questionnaires are sent out to those using the service and their representatives three monthly and “stakeholders” are asked for their views on a yearly basis. The manager uses the feedback to see how the service can continue to develop and make sure people are receiving a good quality care. Although the Providers visit the home regularly they do not complete any report to show how they are monitoring the care and business. Regular meetings are held and everyone has the chance to discuss anything that concerns them. The AQQA was completed and the information gave a reasonable picture of what was happening in the home and information about how it plans to develop over the next year. Personal financial records are clear with detailed records kept. Accounts are held individually, receipts are kept for all expenditure and two signatures are recorded for all transactions. All mandatory training was up to date. Health and safety risk assessments are clear and kept up to date. Records show that the required monthly and weekly checks for water temperatures; legionella, and nurse call system, emergency lighting and fire checks are regularly checked and up to date. All external maintenance contracts are up to date. Accidents are clearly recorded and monitored but there is no system in place to analyse and track trends, which would prevent as far as possible the same accidents occurring. The manager has discussed this with the falls prevention assessor and a suitable form is to be implemented. The staff were in uniform but were wearing lots of jewellery such as rings, wristwatches and quite large earrings. This practice is a possible infection control and safety risk as hands cannot be washed effectively, watches and rings can damage older peoples fragile skin and injury could be caused to ears. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 2 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered persons must make sure that there are clear identification on individual Medicine Administration Records (M.A.R.) Two signatures are needed on all hand written directions. The room temperature needs to be monitored so that 25C is not exceeded and the extractor fan must be repaired. The registered persons must produce a redecoration and refurbishment plan for the home. The registered persons must properly repair the ceiling in the upstairs lounge. The registered persons must ensure that the en suite shower room is repaired. The registered persons must refurbish and deep clean the designated smoking lounge. Timescale of 01/07/08 not met. The registered persons must ensure that all areas have suitable bins with lids. The registered provider must DS0000000236.V370082.R01.S.doc Timescale for action 01/09/08 2 3 4 5 OP19 OP20 OP21 OP24 23 16,23 23 16,23 01/01/09 30/12/08 30/09/08 31/12/08 6 7 OP26 OP37 13,16 26 30/09/08 30/09/08 Page 26 Marina Rest Home Version 5.2 8 OP38 23 complete a report on the conduct of the care home and supply a copy to the registered manager and CSCI on request. The registered persons must 01/09/08 make sure that staff adhere to a dress policy to prevent infection and safety risks. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP38 Good Practice Recommendations The registered manager should carry out monthly analysis of accidents so that she can examine trends to prevent further occurrences. Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marina Rest Home DS0000000236.V370082.R01.S.doc Version 5.2 Page 28 - 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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