Inspection on 13/06/07 for Marine View Rest Home

This inspection was carried out on 13th June 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marine View Rest Home 24/04/08

Marine View Rest Home 28/04/06

Marine View Rest Home 19/10/05

Marine View Rest Home 25/05/05

Marine View Rest Home 13/10/04

Marine View Rest Home 12/05/04

Marine View Rest Home 19/07/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Marine View Rest Home 277/279 Kingsway Hove East Sussex BN3 4LJ Lead Inspector Judy Gossedge Key Unannounced Inspection 13th June 2007 12:00 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 Marine View Rest Home DS0000014214.V338787.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. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marine View Rest Home Address 277/279 Kingsway Hove East Sussex BN3 4LJ 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) 01273 417696 01273 272272 marineview@hotmail.co.uk Mr Mohammed Shareefuddin Ali Mr Mohammed Shareefuddin Ali Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users must be older people aged sixty-five (65) years or over on admission. The maximum number of Service Users to be accommodated is nineteen (19). 28th April 2006 Date of last inspection Brief Description of the Service: Marine View Rest Home is registered as a care home providing services for up to nineteen (19) older people. There is no nursing care provided at the home. District nurses will visit those service users requiring nursing input. The home is located in Hove opposite the Hove Lagoon. There is no parking available at the home, but street parking is available on adjacent streets within the area. Some areas of the home provide views of the sea. There are local amenities within walking distance and access to public transport is nearby. The home is two houses that have been joined together and converted for its current use. Rooms are located over three floors and service users residing in rooms above first floor must be able to independently mobilise. One stairway leading to first floor has a stair lift available. There are eleven single rooms of which two have en suite facilities and four double rooms, of which one has en suite facilities. There are three bathrooms, one shower and five toilets located throughout the home for service users. One single room is below ten square metres. There is a dining room and good-sized lounge room for service users to use. The weekly fees charged at the time of the Inspection range between £305.00 and £411.00. Additional costs are; hairdresser, chiropody, papers and toiletries. The Statement of Purpose, Service Users Guide and copies of previous CSCI inspection reports are available upon request at the home. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and a half hours on 13 June 2007. Prior to the Inspection the Registered Provider who is also the Registered Manager completed an Annual Quality Assurance Assessment (AQAA) and information detailed is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Fourteen service users were resident and nine service users were spoken with, five individually and four in the communal areas. The care that four of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal area. Ten service user surveys were sent out on this occasion and nine completed surveys were returned. The Manager, three senior care workers, cook/activities co-ordinator and one new care worker were all spoken with. Five relatives and visitors surveys were sent out and three completed surveys were returned. Two relatives were spoken with during the Inspection and two relatives were spoken with by telephone after the Inspection. What the service does well: What has improved since the last inspection? That the Statement of Purpose and Service User Guide have been updated to reflect actual practice and promotes confidentiality for current service users. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 6 The Manager stated a policy and procedure has been developed for when medication is taken home with an individual to ensure all medication provided and administered can be accounted for. The sample Medication Administration Records (MAR) charts clearly identified what medication is currently prescribed and administered for service users. The complaints procedure now includes a timescale in which complaints will be dealt with. More regular checks of hot water accessed by service users were viewed and which recorded water is maintained around the recommended safe temperature of 43°C. Induction training to meet the Skills for Care requirements has been put in place. The Protection of Vulnerable Adults (POVA) procedure provides clear guidance for staff that it is not for the home to undertake any investigations. Evidence was in place that service users are involved in the review of their individual plan if care. Care staff is receiving regular supervision. What they could do better: Work has been undertaken to improve the range and frequency that activities are facilitated and this should continue. The quality assurance needs to be further developed to include feedback from visiting health professionals and other stakeholders. The outcome of the quality assurance should be collated and available to view. A number of requirements have been made in relation to health and safety issues in the home to protect service users. That a thorough recruitment process is followed and a POVA First check has been completed prior to staff working in the home, to protect service users. Senior care workers who complete the service users individual care plans are in the process of undertaking a National Vocational Qualification (NVQ) level 3. The Manager and a senior care worker who takes the lead in health and safety issues in the home are due to attend a health and safety course for managers. Service users individual risk assessments should be further developed to detail how any identified risks are to be managed to protect service users. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 7 Environmental checks of the communal areas are recorded and a regular fire check should be undertaken and recorded. The Environmental Health Department is consulted with and any advice received acted upon in relation to the unguarded radiators in the home, to protect service users The East Sussex Fire and Rescue Service are consulted with and any advice acted upon in relation to the lounge door. 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. Marine View Rest Home DS0000014214.V338787.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 Marine View Rest Home DS0000014214.V338787.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): 1, 2, 3, 5 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new service users are individually assessed prior to any admission to ensure that their care needs can be met in the home and there is information about the home for service users and their representatives. EVIDENCE: The Statement of Purpose, Service User’s Guide and a copy of the last Inspection report are available to read in the home. The Manager stated and evidenced that these documents had been reviewed and updated to include the information highlighted as having been omitted following the last Inspection. Eight of the nine service user surveys stated they had received enough information about the home and one had not. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 10 All nine of the service users surveys stated they had a contract/terms and conditions. The Manager stated he now retains a copy of the signed contract/terms and conditions for his own records, but these were not viewed on this occasion. The AQAA detailed that no service users is admitted to the home unless a thorough assessment is undertaken prior to any admission. The Manager and staff who undertake these assessments confirmed that service users are visited prior to any admission and that service users and/or their relatives are encouraged to visit the home. This is to ensure individual service user’s care needs can be met in the home and to provide staff with information on the care to be provided. For the two new service users admitted to the home since the last inspection pre-admission information had been completed. Comments received were,’ I was given a guided tour and also came to lunch and full details of the home’s routines were fully explained to me,’ and ‘ I came for the day and had lunch with service users and staff and was made welcome.’ Intermediate care is not provided in the home. Marine View Rest Home DS0000014214.V338787.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 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care, however, where risks are identified the recording should be developed as to how these risks are to be managed. Personal care and support is provided in a way that maintains and respects the privacy, dignity and lifestyle of the service user. There are policies and procedures in place to manage medicine to be followed to ensure the protection of service users. EVIDENCE: The AQAA detailed that there are policies in place to ensure that equality and diversity issues for individual service users are both identified and incorporated into service users individual plans of care. A selection of six of the service user’s individual care plans was viewed and demonstrated that the detail being recorded continues to be developed. This gives clear guidance to staff of the care to be provided, service user’s personal and health care requirements, dietary needs, social and leisure interests. Supporting risks assessments had Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 12 been recorded and staff spoke of ongoing work in recording risks. This was discussed with the Manager as further consideration and recording should be given to how identified risk are to be managed in particular in relation to falls and where service users go out independently from the home. The care plans viewed had been reviewed to ensure that this information is up-to-date and current care needs are being met and evidenced that service users had been a party to this review. Staff spoken with demonstrated a good understanding of service users’ care needs. Nine service user surveys stated they always received the care and support that they needed and that staff act and listen to what they say. Comments received were, ‘the staff are very understanding when I want to hva a chat,’ ‘they both listen and act on suggestions from changes in details of procedure and are always welcomed,’ ‘very happy with everything. I get all the help I need in my day to day living.’ One relative commented, ‘in my experience my relative is extreemly well looked after in every respect.’ Service users’ health needs are being met at the home. The nine resident surveys all stated that they receive the medical support needed. There were records of health care appointments and the five service users spoken with confirmed that they had access to their GP, dentist, optician and chiropodist if they wish. The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. Feedback received of the care and support provided, observations and information detailed in service users individual care plans was that service users are enabled where possible to exercise choice whilst at Marine View. The feedback from all the service users and relatives was that they were happy with the overall care provided in the home. Service users and relatives, comments included, ‘having been a resident in four care homes, Marine View is deffinately the best of them,’ ‘always a warm welcome at this home. I am pleased my relative is cared for so well. I can relax knowing she is in good hands,’ ‘ I am very happy and contented here,’ ‘takes very good care of the service users,’ ‘they treat each person as an individual by meeting the needs of that person, especially in catering for their likes and dislikes in the meals provided. We seem satisfied with the service given to my relative and to us by giving of information,’ ‘cares are such nice people,’they do a wonderful job,’ and ‘I am very happy here.’ Medication policies and procedures are in place and the administration of medication after lunch was observed. Care workers have received external medication training. The Manager confirmed that a pharmacist regularly visits the home. Where service users are self-administering medication risk assessments should be in place, which gives clear guidance on how the risks are to be managed. The storage and a sample of the recording of the administration of medication were viewed and were adequate. Five service users spoken with confirmed that they were happy with the arrangements for Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 13 the administration of their medication and always received this at the agreed time. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 14 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 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whist resident in the home. There are some opportunities to participate in social and recreational activities provided the frequency of which should continue to be developed. Service users are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: The AQAA and Service Users Guide detailed that home has improved the activities offered by putting in place a designated activities co-ordinator who organises different activities for example, music reminiscence, board games, ball games, cards, drawing and the booking of external entertainment. The activities co-ordinator was spoken with who confirmed activities, which had been arranged, are planned and which had been tried out in the home. Service users spoke of some activities they had participated in and a number of service users go out independently and access local facilities. There was a record of activities provided. Some service users informed the Inspector that they do not participate in activities by choice. Feedback from the service user Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 15 survey was varied and five stated activities were always arranged, two usually and one sometimes arranged. Comments received were, ‘I usually arrange my own activities,’ and ‘they go to considerable trouble to arrange these activities for service users.’ Five service users spoken with on the day of the Inspection confirmed there was a choice of activities provided. It was discussed with the Manager that the range and frequency activities are provided should continue to be developed. Relative’s spoken with and service users who had had visitors commented that there was flexible visiting and that staff are very welcoming. The care and support provided was observed to enable service users where possible to exercise choice whilst at Marine View. The nine service user files viewed and service user and relatives feedback confirmed this. The meals are served mainly in the dining room, although some service users had chosen to have their meal in their bedroom. The cook working on the day stated she held a basic food hygiene certificate. There is a menu in place and service users and staff stated a choice is available at all meals. The Manager and staff also confirmed that during the last year they have been enabling service users to become more actively involved in the menu planning and choice of meals provided. Service users spoke of being asked to choose from the choice available for that day. Special diets are catered for. Lunch on the day was either gammon and pineapple or chicken, with new potatoes in butter and parsley, carrots, peas and gravy, followed by either rice pudding a yoghurt or crème caramel. Fresh fruit is also available. Staff was available to offer any assistance to service users if required and service users were observed to be enjoying their lunchtime meal on the day of the Inspection. Records are kept of individual food consumption, but the recording of breakfast provided should also be recorded to ensure service users have had an adequate diet. The feedback from the service users survey they always or usually liked the meals. Comments received from service users and relatives were, ‘the food is lovely with a lot of home baking,’ ‘there is always seconds if wanted,’ ‘food is very, very good,’ ‘ food is very good,’‘ I enjoy the meals here,’ ‘it is sometimes difficult to make a choice,’ ‘there is a choice for meals and I am able to have what I like,’ and ‘except at the weekend we have a choice of menu so there is seldom any need to eat anything that are dislikes.’ Marine View Rest Home DS0000014214.V338787.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 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided, also to ensure that service users are protected from abuse but it should be ensured that these are followed to protect service users. EVIDENCE: There is a complaints policy and procedure in place, which has been amended to detail the timescale in which any complaint will be dealt with. A copy of the complaints policy has been given to all the service users. The AQAA detailed that one complaint has been received since the last inspection, which the CSCI had received and was passed to the home to investigate. All the service users surveys stated they knew who to speak to if they were not happy and how to make a complaint. Service users spoken with and all the relatives confirmed that it was an environment where they would feel comfortable raising any concerns with the staff or the Manager. There are policies and procedures in place in relation to the protection of vulnerable adults, which the Manager stated and demonstrated it has been amended to ensure it provides clear guidance for staff that it is not for the home to investigate any allegations. It should be ensured that these are followed, see Standard 29 for shortfalls in recruitment procedures. No Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 17 complaints have been received which have been investigated under adult protection procedures. Care workers spoken with had an awareness of adult protection procedures and stated they had received training/update. The sample of training records viewed also confirmed attendance at this training. The Manager stated he has also attended further training during the year. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 18 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, 25 and 26. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: A tour of the building was made. The AQAA detailed that service users are actively involved in the décor and furnishing of their individual bedroom and communal areas. The home is decorated and furnished in a homely style. The Manager spoke of work, which has been undertaken since the last Inspection with the purchase of a new cooker and refrigerator in the kitchen and plans to renew some of the kitchen units. One relative also stated the home had been redecorated inside and out before Christmas 2006 and how nice it all looked. The AQAA detailed that following feedback from the service users further plans Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 19 for the home included the provision of a walk-in shower, renew the kitchen flooring, retile the first floor bathroom and improve the back garden. Also the Manager is looking into the feasibility of fitting a passenger lift in the home subject to meeting all current requirements. There are eleven single bedrooms on all floors of which two have en-suite facilities and one does not meet the minimum space requirements and four double bedrooms of which one has en-suite facilities. These were all being used as single bedrooms at the time of the Inspection and the Manager stated these are only used as double bedrooms if this is with the agreement of the service users. Service users are able to control the temperature in their own bedrooms. All bedrooms have an emergency call bell system and where asked service users stated that staff responded promptly. Bedrooms viewed had been personalised and reflected a range of individual styles and interests. One bedroom viewed currently vacant had been redecorated and re-carpeted ready for occupation. There are adequate toilets and assisted bathing facilities in the home. Heating is provided by a central heating system with most radiators now guarded in the home. The radiators in the four rooms at the front of the home have not been guarded and are not of guaranteed low surface temperature. The Manager stated that there was no plan to cover the remaining four radiators and that risk assessments have been undertaken and recorded. This was discussed with the Manager and a Requirement has been made to consult with the Environmental Health Department to ensure that current safeguards in place are adequate and to act upon any advice received. Records were viewed of the regular testing of the hot water in the home to ensure that the hot water outlets accessed by service users is maintained at close to the recommended safe temperature of 43° C. Where asked service users confirmed that there was adequate heating and access to hot water. There is a separate dining room and a large lounge on the ground floor. There is a stair-lift between the ground, and first floor within the home, however there is one step that must still be negotiated to access the opposite side of the building. Service users with bedrooms on the second floor will need to be able to independently mobilise to access these bedrooms. CCTV cameras have been fitted at the home, which are restricted to the entrances of the home for security and will not impose on the privacy of the service users residing at the home. The home was clean and free from offensive odours. The AQAA detailed that there is a policy in place for preventing infection and managing infection control and that department of health guidance has been used to assess the homes current infection control management. The content of these policies were not read on this occasion. Seven service users surveys stated the home Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 20 was always fresh and clean and two usually. Comments received were, ‘the home is lovely and clean,’ and ’definitely.’ There is a paved area at the rear of the home Recordings of the regular routine fire checks carried out in the home were viewed. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 21 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 and 30. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A robust recruitment procedure needs to be in place to ensure service users are in safe hands at all times. Care workers are being provided with training to ensure they can meet the care needs of the service users. EVIDENCE: Staff spoken with confirmed that two members of care staff are deployed to work in the home during the day with the Manager. At night the home deploys one ‘waking night’ member of care staff and there is someone on call at night if additional assistance is required. The night staffing provided should be kept under review to ensure that the care needs of the service users resident continue to be met. There are also ancillary staff that work in the home and who cover catering, domestic and laundry tasks. Relative’s stated that they felt there were adequate numbers of staff on duty during their visits and that felt that their relative received the care and support that they needed. Standard 28 has been met as sixty percent of the staff have achieved their national Vocational Qualification (NVQ) level 2 or equivalent in care. Senior staff confirmed they were currently working towards NVQ Level 3. The AQAA Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 22 detailed that six care staff hole NVQ level 2 in care and a further four care staff are currently working towards NVQ level 2 in care. The recruitment process followed was viewed for the one new member of care staff working in the home who had been recruited since the last inspection. A clear record of the recruitment checks undertaken and when should be in place to evidence the recruitment process. In this instance two written references had not been received and a completed a Criminal Records Bureau check (CRB)/a Pova First check had not been received prior to the member of staff commencing work in the home. The Manager stated that induction training to meet the requirements of the General Skills for Care induction standards had been introduced for the new staff to complete and the new member of staff who had been recruited since the last inspection was spoken with who confirmed and they had received an initial induction in to the home. Staff spoken with and records viewed confirmed they had had an annual appraisal. Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home benefits from a Manager who ensures an open, supportive, homely and caring environment, but the quality assurance process needs to be further developed and the outcome be published annually. Systems need to be further developed to ensure a safe environment for staff and service users. EVIDENCE: The Registered Provider is also the Registered Manager for the home, has owned the home for sixteen years and has obtained his knowledge and skills in care through out this period of owning the home. Staff confirmed that he is Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 24 supportive and approachable. The Manager stated he has completed the required elements of NVQ Level 4 in Care and is now working towards the Registered Managers Award. There have also been further training opportunities which the Registered Manager has attended. A quality assurance system has been developed. It was evidenced that feedback about the service provided has been sought from service users, but this needs to be extended to relatives/representatives and other professionals who attend the home, all of which needs to be collated and available to reference. The AQAA detailed that policies and procedures were in place and had been reviewed. A regular recorded visit of the home to meet Regulation 26 has been made. Service users individual plans of care had been reviewed. The home does not hold any money for service users at the home. Service users either maintain their own finances or relatives will handle their financial affairs. The Manager confirmed that it would be ensured that receipts are kept of any purchases bought on a service users behalf to safeguard the service users and the staff. Supervision for all care staff has been introduced and maintained to meet the requirements of Standard 36. Currently the Manager has employed an external consultant to undertake this task. Training records were not collated but detailed on individual staff member documentation, so it was not possible to evidence that all staff completed the required training. But staff spoken to and the sample of staff documentation viewed evidenced staff had received training or were due to receive training in moving and handling, basic food hygiene, first aid and infection control within the required timescales. The Manager and a senior care worker who takes the lead for health and safety issues in the home stated they were both due to attend a course on health and safety for managers the following week, where they expected to receive further guidance in risk assessment. The AQAA detailed that the maintenance of equipment and services has been carried out. A fire risk assessment is in place for the home. A regular fire check is not undertaken in the home and recorded. This was discussed with the Manager who stated he had received further guidance, which had made him aware of the need to complete and record these checks and stated this would be addressed. Fire doors have been fitted with self-closing devices. One door to the staircase up to the second floor did not appear to fully close. This was discussed with the Manager who was able to confirm this door closed when the fire alarm went off unexpectedly during the afternoon of the Inspection. The door into the lounge is not fitted with any self-closing device and was just left Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 25 open. This was discussed with the Manager who agreed to get advice from the East Sussex Fire and Rescue Service and act upon any advice given. Staff spoken with and records evidenced that staff attended fire training and there are also fire drills facilitated in the home. Environmental risk assessments of the service users bedroom had been undertaken and recorded. The Manager stated that checks were also undertaken for the communal and the outside areas, but these checks were not recorded and should be. Records of any incidents and accidents in the home were viewed Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 26 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 3 X 2 Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4) Requirement That risk assessments are further developed to detail how any identified risks are to be managed to protect service users. That for all staff working in the home a thorough recruitment process is followed. That a POVA First check has been completed prior to staff working in the home, to protect service users. The outcome of the service user quality assurance is made available to read. Feedback sought from other stakeholders to ensure the quality of the service provided. That Environmental Health Department is consulted with and any advice received acted upon in relation to the unguarded radiators in the home, to protect service users That East Sussex Fire and Rescue Service is consulted with DS0000014214.V338787.R01.S.doc Timescale for action 31/07/07 2. OP29 19 (1) (b) 31/07/07 3. OP33 24 (1) (2) (3) 31/08/07 4. OP38 13 (4) 31/07/07 5. OP38 23(4)(i) 31/07/07 Marine View Rest Home Version 5.2 Page 28 and any advice acted upon in relation to the lounge door in the home, to protect service users. 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 Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Marine View Rest Home DS0000014214.V338787.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!