Inspection on 25/05/05 for Marine View Rest Home

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Marine View Rest Home 24/04/08

Marine View Rest Home 13/06/07

Marine View Rest Home 28/04/06

Marine View Rest Home 19/10/05

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 Jennie Williams Announced 25 May 2005 09.30 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 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 H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Marine View Rest Home Address 277 279 Kingsway Hove East Sussex BN3 4LJ 01273 417696 01273 241975 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mohammed Shareefuddin Ali Mrs Gloria Toll Care Home 19 Category(ies) of Old age, not falling into any other category (OP) registration, with number (19) of places Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users accommodated must not exceed nineteen(19). 2. The service users accommodated will be aged sixty-five (65) years or over on admission. Date of last inspection 13 October 2004 Brief Description of the Service: Marine View Rest Home is registered as a care home providing services for up to 19 older people. There is no nursing care provided at the home. District nurses will visit those residents 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 residents residing in rooms above first floor must be able to independently mobilise. One stairway leading to first floor has a stair lift available. There has been previous discussion of installing a stair lift from the first floor to the second floor. This will not be actioned following advice from the fire brigade. There were 13 residents living at the home on the day of the inspection. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Marine View Rest Home will be referred to as ‘residents’. This announced inspection took place over eight hours on the 25 May 2005. A tour of the home was provided. Staff files, some policies and procedures, records, care plans and MAR charts were inspected. Residents and staff were spoken with throughout the inspection process. The environment and some individual rooms were spot-checked. The Inspector ate lunch with the residents and an organised activity was observed. The pre inspection questionnaire was sampled and the Inspector received eight comment cards from residents and four comment cards from relatives/visitors. All comment cards demonstrated that residents and visitors are overall satisfied with the care and services provided at the home. What the service does well: What has improved since the last inspection? What they could do better: There are shortfalls within the documentation kept at the home. Documentation needs to be improved to evidence that what is actually done can be evidenced when tracking information. Eg: bathing of residents. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 6 Documentation also needs to be improved to safeguard residents, as well as the staff working at the home. eg. risk assessments. Recruitment procedures also require to be more robust to ensure the safety of residents residing at the home. Improving cleaning and maintenance of the home and appropriate warning signs in places would ensure residents live in a clean and safe environment. The safety of the residents will be improved if fire doors closed securely and kept clear of obstacles. 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. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 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 standard(s) 1, 3, 4 & 5 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home. Standard 6 is not applicable as the home does not have dedicated accommodation to provide intermediate care. EVIDENCE: The home has a Statement of Purpose and Service User Guide that is available upon request and provides prospective residents and their representative information on the services and care provided at the home. It needs to be reflected in the Service User Guide that a copy of the most recent inspection report is available at the home upon request. All prospective residents are assessed prior to moving into the home. Most residents admitted to the home require minimal assistance in their daily living activities. The location of the room available for admission is taken into account when assessing prospective residents, as some are only accessible for those who can safely and independently mobilise. Copies of social services assessments are obtained wherever possible. Prospective residents are Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 9 welcomed to visit the home prior to admission if they wish. Three residents spoken with confirmed that they visited the home prior to moving in. Staff individually and collectively have the skills and experience to deliver the services and care which the home offers to provide. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Residents and staff may be placed at risk due to lack of risk assessments. Some needs are at risk of not being met due to lack of information in care plans and not being regularly reviewed. Health needs of individuals are at risk of not being met due to lack of clear documentation and staff retaining too much information in their heads. Management would reduce the risk of controlled drugs going missing if a record was to be kept on ingoing and outgoing medications. EVIDENCE: There are currently two different care plan formats being used within the home. Staff are choosing to use which format they prefer. One format is comprehensive and provides information on individual needs as stated in NMS 3.3 and the other is not as comprehensive. Management must decide which system is to be used at the home and provide a structured system for staff and residents. Care plans must include all areas of needs as stated in NMS 3.3. There was evidence that not all care plans are being reviewed on a monthly basis or as needs change. Care notes are not written on residents, but there is a report book used to document any identified changes. It is recommended that changes be recorded in an individuals’ file and reflected in the care plan. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 11 Risk assessments must be undertaken to safeguard residents and staff. It was made an immediate requirement that risk assessments are undertaken for residents who independently leave the home and who have access to the first floor balcony. Risk assessments will clearly demonstrate that residents are capable of participating independently in these activities. There is a bathing record kept, but is not being completed accurately. It demonstrated that an individual had only been provided with a strip wash for a month. It was confirmed that this resident had been showered/bathed within this period. It was discussed with management to iterate to staff the importance of maintaining clear documentation. If the care of an individual needs to be tracked, it is the documentation that will demonstrate this. There was no way the Inspector could easily identify when an individual has been seen by a visiting health professional eg: audiologist, optician. Dates of visiting professionals are recorded in the report book. The Inspector would have had to spend a lot of time reading through the pages to find dates. The manager confirmed that health needs are being met. It is recommended that a checklist is implemented and stored with the care plan of an individual to clearly identify when visits have been undertaken. It was confirmed that there are policies and procedures in place for all aspects of dealing with medications. There is one controlled drug being used at the home. The Inspector was unable to confirm if there was the correct amount of tablets on the premise as there were no records of the amount of incoming tablets. It was recommended to management that a record of controlled drugs be maintained to safeguard the resident and staff. Medications were being signed for appropriately. Residents spoken to felt their privacy and dignity and are respected. All eight comment cards received identified that the individual felt their privacy is respected. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Residents are provided with opportunities to participate in activities. Residents’ lifestyles are flexible and are the individuals’ choice. The home does not manage any finances for individuals. EVIDENCE: Residents spoken with confirmed that they are happy with the activities provided at the home. Two residents independently leave the home for walks in the local area. Residents confirmed that their lifestyle is their own choice. Eg. times for getting up and going to bed, what days they prefer to bath etc. There was a music entertainer visiting the home on the day of the inspection. Residents were observed enjoying and participating in this activity. Seven out of eight comment cards received identified that the home provides suitable activities. One demonstrated that ‘sometimes’ suitable activities are provided. Visitors are welcomedasked not to visit the home before 9:00am and after 10:00pm. All people in the home are happy with these times. This is for the privacy of the residents. There is a visitor’s book that all people must sign when entering the home. The home is not an appointee for any resident. The registered provider will collect an individuals pension allowance if required and passes this money to Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 13 the individual. Relatives look after an individuals’ money, if required. Secure facilities are provided for residents who keep their own monies. The Inspector enjoyed a roast lamb meal with residents. Residents were complimentary about the food provided at the home. All eight comment cards received from residents demonstrated that they liked the food. The menu provided to the Inspector did not demonstrate that there was an alternative meal available. It was confirmed that an alternative is provided if an individual does not like what is on offer. The alternative choice should be reflected in the menu. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18 The home has adequate systems in place to ensure that complaints are dealt with appropriately. Staff are provided with sufficient information to inform them of the correct procedures if an allegation of abuse is made. Residents’ legal rights are protected. EVIDENCE: The have been no complaints made to the home or to CSCI since the last inspection. Staff have received training in the Protection of Vulnerable Adults. There have been no allegations of abuse made since the last inspection. It was confirmed that one resident completed a postal vote for the recent election. No one else chose to be involved in the political process. All eight resident comment cards received identified that people know who to speak to if they are unhappy with their care and that they feel safe at the home. All four relative/visitor comment cards demonstrated they were all aware of the home’s complaints procedure and no one has ever had to make a complaint. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 22, 24, 25 & 26 The location of the home provides opportunities for residents and visitors to access local amenities and transport. The admission of residents may be restricted due to the layout of the home. A written cleaning schedule and regular checks would help to ensure the home is kept clean at all times. EVIDENCE: The home is located in a residential area of Hove and is opposite the Hove Lagoon. Rooms are located over three floors. Residents must be able to independently mobilise safely to reach the rooms on the top floor. There is a chair lift available to the first floor, and a steep stairway between first and second floor. Residents are able to bring personal possessions with them into the home. Not all individual rooms were inspected. Rooms were randomly spot-checked. The home currently uses an agency cleaner for three hours a day, Monday to Friday. The care staff working at the home does the laundry duties. Some Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 16 areas of the home need to be more thoroughly cleaned and some furnishings are old and in need of repair or replacement. The home needs to develop a cleaning schedule to ensure all areas of the home are cleaned. Areas that were observed needing thorough cleaning were: under beds and bases of beds, commodes, sinks and some carpets etc. There were some chairs noted in individual rooms that are in need of repair or replacement. The shower chair in the ladies toilet downstairs was mouldy and needs thorough cleaning or to be replaced. One individuals’ room was in need of refurbishing and redecorating. It was confirmed by management that the individual likes his room and does not want it changed. The room was in great need of decoration and was offensive smelling. The individual needs to be encouraged to allow the room to be refurbished. Some pillows appeared stained and in need of being replaced. The home needs to allow in the budget for replacement of furnishings and maintenance. Some areas are in need of decoration and maintenance. Radiators are required to be guarded or replaced with guaranteed low temperature surfaces. Hot water taps were recorded to be distributing water from 37°C to 54°C. Action must be taken to ensure all hot water taps dispenses water near the recommended 43°C. It was made an immediate requirement that warning signs are placed at hot water outlets that deliver water above the recommended temperature. The home has been assessed by an Occupational Therapist. The report is very thorough and highlights areas for improvements. It is recommended that the home complies with the recommendations made within this report, particularly the ones relating to the health and safety of residents and staff. One bathroom had towels left within it. Towels should not be left in communal areas. This practice does not promote good hygiene practices. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Residents would be protected and safeguarded better if the home implemented robust recruitment procedures. Staff were observed to have a good professional rapport with residents. Staff spoken with are happy working at the home. EVIDENCE: Staff and residents spoken with confirmed that they felt there were sufficient numbers of staff on duty at all times. The rota provided to the Inspector demonstrated there are two carers working during waking hours. One staff member works a waking night. The rota must clearly demonstrate who is working in what role. The cleaners working hours must also be included. Staff prepare the evening meal. This demonstrates that there will be only one staff member on the floor to care for residents. This procedure must be reviewed, as two staff are required to be on duty to care for the residents. The layout of the building needs to be taken into account when deciding on suitable action to be taken. Management should consider employing a supper cook to ensure enough staff are on duty to care for residents at all times. Staff spoken with confirmed that they have received all mandatory training. Residents were very complimentary about the staff working at the home. One comment received was ‘they are more like friends than working for us’. There is currently three out of the eight care staff employed that have achieved NVQ level 2 qualifications and one currently half way through these studies. Another two staff will be commencing NVQ level 2 studies in June Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 18 2005. As there is evidence that the home is working toward the required 50 ration of NVQ trained staff, this has been reflected as a recommendation. It was confirmed that staff receive mandatory training. There were shortfalls in the documentation required to be kept on all staff. These were discussed at length with the provider. Staff files must comply with Schedule 2. All new staff must have POVA clearance prior to commencing employment, and then only work supervised at all times until a full CRB check has been returned. Ensuring application forms are fully completed will assist the home in tightening up on recruitment shortfalls. The provider was trying to contact a new staff member on the day of the inspection to advise them that they cannot commence employment until all relevant checks have been obtained. Regulation 26 reports are sent to CSCI on a monthly basis. The manager has recently been completing these reports. The registered provider must complete regulation 26 reports and a copy supplied to the manager and CSCI. Two different report formats were provided to the registered provider, for guidance on more detailed information to be forwarded and to use as a tool for his own monitoring purposes. The registered provider and manager were also informed of Regulation 37 reportable incidents. Notice must be given to the CSCI without delay and not just included in the monthly reports. This came to light as a resident had recently died and the inspector had not been notified of this incident. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 37 & 38 There is clear leadership and guidance for staff to ensure residents receive consistent quality care. A developed and implemented quality assurance and quality monitoring programme would enable management to assess the suitably of services provided at the home and identify areas that can be improved. The safety of residents will be promoted better if fire doors close securely and remain clear of obstacles. EVIDENCE: The manager has been managing the home for the past 25 years. The manager has not undergone any management training and does not propose to undertake any management qualifications. It is recommended that the manager undertakes relevant management training. The registered provider has obtained a care management qualification. Both manager and provider will participate in training sessions provided to staff. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 20 Staff spoken with found management approachable. There are policies and procedures in place that are accessible to whoever wishes to access them. It is recommended that a quick reference guide be developed and implemented to allow staff quick easy access to the relevant policy and procedure they require. The pre inspection questionnaire provided by the home demonstrated that all relevant policies and procedures are in place. The pre inspection questionnaire demonstrated that all maintenance and associated records are maintained and up to date. Records are kept securely within the home and are used within accordance of the Data Protection Act 1998. The home must ensure that records as stated in Schedule 2 and 4 are maintained and kept up to date. Fire doors were observed not shutting securely and one fire door on a magnetic release device was obstructed from closing properly should it have to be released. Some individual fire doors were observed to being wedged open with inappropriate devices. Any shortfalls regarding fire safety measures that the Inspector noted has been identified in the recent Fire Risk Assessment undertaken by a Fire Safety Advisor. It is required that the homes addresses the shortfalls identified in that report. An immediate requirement was made that fire doors are not wedged open and that fire doors close effectively. There has been no formal quality assurance/quality monitoring or audits undertaken at the home. The home needs to develop and implement an effective system to enable management to assess the suitably of services provided at the home and identify areas that can be improved. Views of residents/relatives, staff and other stakeholders (eg: GP’s and other visiting health professionals) in the home should be obtained and evaluated. The registered provider did not think this was needed as CSCI undertakes questionnaires. It has been explained that the home must reintroduce their own system and comment cards produced by CSCI are used as part of the inspection process. There are some areas in the home that have sloping ceilings. It is recommended that warning signs be placed in these areas. There are two stairs immediately upon opening the door of a bedroom. It is recommended that a warning sign be placed to alert all visitor/residents of these. Any other shortfalls in the health, safety and welfare of residents have been addressed in the relevant sections of the report. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x 2 x 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 2 x 3 x 2 2 Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5.1(d) Requirement That the Service User Guide states that a copy of the most recent inspection report is available at the home upon request. That care plans are standardised and include all areas as stated in NMS 3.3. That care plans be reviewed on a monthly basis or earlier if the needs change. That risk assessments be undertaken for service users who independently leave the home and who have access to the first floor balcony. That the cleanliness and maintenance within the home is improved. That a cleaning and maintenance schedule is implemented. That the mouldy shower chair in the downstairs ladies toilet is thoroughly cleaned or replaced. That the home allows in the budget for the replacement of furninshings/bedding and maintenance. That all radiators are guarded or replaced with guaranteed low temperature surfaces. That warning signs are placed at Timescale for action 31.07.05 2. OP7 15.1 31.07.05 3. OP7 13.4 31.07.05 4. OP26 16.2(k) & 23.2(d) 31.07.05 5. 6. OP26 OP19 23.1(d) 25 30.06.05 30.11.05 7. 8. OP25 OP25 13.4 13.4 30.11.05 28.05.05 Page 23 Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 9. OP25 13.4 10. OP27 17.2, Schedule 4(7) 18.1(a) 11. OP27 12. OP29 Schedlue 2 13. 14. 15. 16. 17. 18. OP33 OP37 OP37 OP38 OP38 OP33 26 37 Schedule 2&4 13.4 & 23.4 23.4 24 hot water outlets that dispense water above the recommended temperature. That all hot water taps dispense water around the recommended 43°C. Pre set valves will be required to be installed. That the rota clearly states who is working in what position. Domestic staff hours must be included. That the home reviews the procedures for the provision of evening meals. Two staff are requried to be on duty to care for residents. That staff files comply with Schedule 2. All staff must have POVA clearance and CRB completed prior to commencing employment.(Timescale 01.12.04 not met) That the Registered Provider completes Regulation 26 reports. That the home complies with Regulation 37 reports. That records as stated in Schedule 2 and 4 are maintained and kept up to date. That fire doors are not wedged open and that fire doors close effectively. That the shortfalls identified in the Fire Risk Assessment are complied with. That an effective quality assurance and quality monitoring system is developed and implemented. 31.07.05 30.06.05 30.06.05 30.06.05 30.06.05 25.05.05 31.07.05 29.05.05 31.07.05 31.08.05 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 Good Practice Recommendations H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 24 Marine View Rest Home 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Standard OP7 OP7 OP8 OP9 OP24 OP26 OP22 OP28 OP31 OP33 OP38 That changes of an individual is recorded in the individuals file and reflected in the care plan. That it is iterated to staff the importance of maintaining clear documentation. That a checklist be implemented and stored with the care plan of an individual to clearly identify dates that visitng health professionals have visited. That a clear record of controlled drugs be maintained to safeguard service users and staff. That the individual identified at inspection is strongly encouraged to allow the home to redecorate and refurbish their room. That towels are not left in communal areas. That the recommendations form the Occupational Therapists report is compied with. That the home continues to work towards the ratio of having 50 of care staff with NVQ level 2 or equivalent qualified. That the manager undertakes relevant management training. That a quick reference guide be developed and implemented to allow staff quick easy access to the relevant policy and procedure they require. That warning signs be placed in the areas noted in the report and discussed at inspection. Marine View Rest Home H59-H10 S14214 Marine View Rest Home V219217 250505 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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