Inspection on 28/04/06 for Marine View Rest Home

This inspection was carried out on 28th April 2006.

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

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

Other inspections for this house

Marine View Rest Home 24/04/08

Marine View Rest Home 13/06/07

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 Marine View Rest Home 277/279 Kingsway Hove East Sussex BN3 4LJ Lead Inspector Jennie Williams Unannounced Inspection 28th April 2006 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 Marine View Rest Home DS0000014214.V288361.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.V288361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marine View Rest Home Address Marine View Rest Home 277/279 Kingsway Hove East Sussex BN3 4LJ 01273 417696 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) Mr Mohammed Shareefuddin Ali Vacant 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.V288361.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). 19th October 2005 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 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 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 residents. One single room is below ten square metres. There is a dining room and good-sized lounge room for residents to use. The weekly fees range between £298 and £403. Additional costs are; hairdresser (£6 - £20), chiropody (£10), papers and toiletries. This information was provided to the CSCI on 25 April 2006. Copies of previous CSCI inspection reports are available upon request at the home, however this information is not readily provided to the public in the homes Service User Guide. Prospective residents and their relatives find out about the service through social service referrals, word of mouth, from living in the area and information is obtainable on the CSCI website. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 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 unannounced inspection took place over approximately eight and three quarter hours on the 28 April 2006. The Inspector returned to the home for a short period on the 2 May 2006 to provide feedback to the registered provider. There were 14 residents residing at the home on the day of the inspection. Eleven residents, of both genders and over the age of 65 years, were spoken with during the inspection. Two residents independently completed resident surveys and on discussion with eight other residents, the Inspector assisted them to complete the surveys. One of these residents did not wish to participate and this was respected. Four out of seven GP comment cards sent out were returned. Three residents, two female and one male, care plans were looked at in detail. The registered provider, the cook/carer, two staff and a staff waiting to commence employment were spoken with. A pre-inspection questionnaire was received following the site visit at the home. No contact was made with relatives. Three staff files were inspected. One care plan was looked at in detail. Specific areas of care needs were looked at in three other care plans. Previous requirements at the home were assessed to ensure compliance. The environment and some individual rooms were looked at. The Statement of Purpose, Service User Guide, staff rota, menus, accident forms and activity records were inspected. No health and safety records were viewed as this information has been provided in the pre-inspection questionnaire. What the service does well: What has improved since the last inspection? Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 6 The home has undertaken work and has complied with twelve out of the sixteen requirements made at the last inspection. All new admissions are now assessed prior to moving into the home, as previously some residents had been admitted without any assessment undertaken by the home. All residents are provided with a contract/terms and conditions. All forms in use are being dated and signed and accident forms are fully completed with all relevant information and the reporting of significant events to the CSCI has improved. Care plans have been standardised to the same format to provide consistency for residents and staff and provide clear guidance for staff on how to meet the assessed needs of residents. Daily records are now being stored within an individual’s file, promoting confidentiality. Medication procedures are generally improving and sample signatures of staff administering medication are now in place. Records are being kept of all visitors to the home. The recruitment procedure is more robust and staff do not commence employment without all relevant checks having been undertaken to safeguard residents. The cleanliness and maintenance within the home is continuing to be improved and maintained. There was evidence that the personal care for residents, particularly eye care, had improved as recommended at the last inspection. Work is continuing to be done to ensure all hot water outlets are delivering water around the recommended 43°C. What they could do better: The Statement of Purpose and Service User Guide needs to be updated and amended to provide clear information for the public on the care and facilities provided at the home, whilst ensuring confidentiality is maintained for those currently residing at the home. The information obtained at the pre assessment needs to be expanded to ensure that the home can evidence that all of the assessed needs can be met within the current services. It is an outstanding requirement that residents/representatives be involved in the reviewing process of care plans to ensure that preferences and choice are taken into account. Improvements need to be made to the risk assessment procedures to promote the health and safety of residents and provide clear guidelines for staff on action to take to reduce the risks. Medication procedures must be improved to provide clear information on what medication is currently being administered for individuals and procedures to be followed if an individual needs to take medication out of the home environment, for example, if they visit family for a weekend. It remains an outstanding requirement to ensure that suitable and fulfilling activities are provided to promote a stimulating and fulfilling stay for residents. The Protection of Vulnerable Adults (POVA) procedure needs to be amended to ensure it provides clear guidance for staff that it is not for the home to investigate any allegations. Induction and foundation training need to be undertaken by all new staff within the given timescale to demonstrate that new staff are competent in fulfilling their roles. Regular feedback should be sought from relatives/visiting health professionals and other stakeholders within the community on a regular basis. A structured quality assurance and quality monitoring programme would enable management to assess the suitably of Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 7 services provided at the home and identify areas that can be improved. There are a number of health and safety issues that require addressing to ensure residents, staff and visitors at the home are not put at risk, including fire doors closing effectively and radiators to be guarded. 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 DS0000014214.V288361.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.V288361.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The information provided to prospective residents/representatives does not provide accurate, clear and up to date information about the care and services at the home so that an informed decision can be made if the home can meet their needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide available for prospective residents/representatives outlining care and services provided at the home. A copy of this document was provided on the day of the inspection. This document needs to be updated to provide accurate information for the public and must not make reference to named individuals. This document should contain a copy of the most recent inspection report or at least provide information to the reader that it is available at the home to read. The Statement of Purpose should clearly advise prospective residents/representatives that residents must be able to independently mobilise if their room is above the first floor. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 10 Residents are provided with a contract/terms and conditions. The content of this document was not read. The registered provider confirmed that all residents have signed a contract. The home has not kept a copy of these signed documents. The registered provider confirmed that there was no one residing at the home from any minority ethnic communities, social/cultural or religious groups with any specific need or preferences. All prospective residents are assessed prior to moving into the home. The pre assessment information is generally adequate, but lacks sufficient information for staff when developing the initial care plan eg, specialist dietary requirements, if hearing aids/dentures are used etc. Prospective residents/representatives are encouraged to visit the home prior to moving in. The layout of the home and limited mobility aids available may prevent the admission of some residents. The location of the room available is taken into account prior to admitting anyone. Of the residents that were asked all confirmed that themselves or a representative had visited the home prior to moving in. Five out of nine resident surveys stated that they received enough information about the home prior to moving in. The home does not have dedicated accommodation to provide intermediate care. Marine View Rest Home DS0000014214.V288361.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Care plans provide clear guidance for staff on how to meet the assessed needs of the residents, however risk assessments must be improved to promote the safety and well being of residents. EVIDENCE: Care plans in use provide staff with clear guidance on the assessed needs of the individuals. One care plan inspected provided the Inspector with clear information on the assessed needs of the resident. Other specific areas looked at in other care plans also provided information on specific needs of the individual. Staff spoken with also demonstrated a good understanding of the residents’ needs. All residents’ surveys state that they receive the care and support they need. There was evidence that residents were involved in the initial drawing up of the care plan. There was evidence that care plans are being reviewed on a monthly basis, however no evidence that residents/representatives were involved in the reviewing process. Two residents stated that staff don’t discuss their care and one stated that staff do discuss their care. Some residents Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 12 spoken with were not familiar with their care plan, however staff involved in the reviewing of care plans informed the Inspector that they do review the care plans with the residents. Residents’ health needs are being met at the home. All comment cards received from GP’s state that staff demonstrate a clear understanding of the care needs of residents and any specialist advice they give is incorporated into the individuals’ care plan. All showed that they are satisfied with the overall care provided to residents within the home. Nine resident surveys stated that they receive the medical support needed. One resident confirmed that they receive regular hearing checks. One resident observed to be wearing glasses confirmed that they receive regular eye checks. One resident stated that it is by their choice that they don’t have hearing, eye or dental checks and this choice is respected by the home. Care notes written on individuals did not provide clear information on the health and welfare of residents. Writing ‘fine and well’ does not provide sufficient information on the well-being and health needs of individuals and provide the reader with sufficient information to track the progress of an individual. Risk assessments for individuals are in place, however do not provide information on the overall risk for the individual and are not being completed by appropriately qualified staff. Additional risk assessments need to be in place, with particular attention to falls. Medication was being signed for at the time of administration and there are suitable records of controlled drugs being kept. Medication is stored securely. It was noted that a resident recently went to stay with relatives outside of the home environment. There was no evidence that clear procedures are in place for when medication is taken home with an individual to ensure all medication provided and administered can be accounted for. Some Medication Administration Records (MAR) inspected did not provide a clear guidance if a medication was still in use or not. All GP comment cards state that the residents’ medication is appropriately managed in the home. Residents’ privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were heard calling them by their preferred name. Residents receive their post unopened and can arrange to have a private telephone installed in their own room if they wish. All GP comment cards received stated that they are able to see their patients in private. Marine View Rest Home DS0000014214.V288361.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents lifestyle within the home is their own choice, however residents are not provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: There were mixed feelings about the provision of activities provided at the home. Some residents stated that they would like to go out more often. The registered provider and staff spoken with confirmed that when outings were arranged, residents either did not participate or wished to return to the home soon after leaving it. The registered provider confirmed that outings will commence to be arranged again when the weather improves. Out of the eight residents surveys, two stated there are usually activities provided that they can take part in, five stated sometimes and one identified that there are never activities provided that they can participate in. Some residents informed the Inspector that they do not participate in activities by choice. The record of activities was inspected and demonstrated that activities are not regularly provided. It should be recognised that staff have improved the documentation of activities, however no records of who participated were recorded or who may have been offered an activity but declined by choice. It was confirmed by the registered provider and staff, that other activities had been trialled at the home, but residents were not responsive to them. There is no activity person Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 14 employed at the home, staff on duty provide residents with activities. There was no activity programme seen on the day of the inspection. Some of the activities include puzzles, games, chatting with staff. Residents were very complimentary about a ‘music man’ who visits the home every four to six weeks and thoroughly enjoy his visit and singing along to the songs. The Statement of Purpose identifies that a singer visits fortnightly to entertain residents. This information is incorrect and requires amending. Residents’ spoken with confirmed that their lifestyle is their choice within the home. Three residents regularly go into the community alone. Visitors are encouraged and welcomed at the home. Some residents spoken with confirmed that they have visitors come to the home and are able to see them in private. There is a visitor’s book that all visitors must sign when they enter and leave the home. All comment cards completed stated that seven residents always like the meals provided at the home and two usually liked the meals. It was confirmed that there is always a choice available. The home is due to be visited by Environmental Health next month. The kitchen was clean on the day of the inspection. Residents were observed to be enjoying their lunchtime meal on the day of the inspection. The menu provided to the Inspector demonstrates that there is a variety of nutritional food provided throughout the week. The cook confirmed that she regularly discusses the food with residents. One resident requires a softened diet and likes the food to be liquidised. It was noted that all ingredients were liquidised together. It was suggested to the cook that the ingredients are liquidised individually to promote presentation and to keep the individuals’ taste buds stimulated. The Inspector was informed on the second visit to the home that this was tried, but it is the choice of the individual to continue having the ingredients liquidised together. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents feel comfortable to complain and feel that their concerns will be acted on. Written procedures for the Protection of Vulnerable Adults are not correct, however staff demonstrated a good understanding of the procedures that must be followed. EVIDENCE: There have been no complaints made to the CSCI or to the home since the last inspection. There is a suitable complaints procedure in place, however this needs to provide a timescale to inform the complainant of the time within the home will deal with their complaint. The majority of residents spoken with confirmed that they know how to make a complaint and to whom they would speak. One resident confirmed that they had a copy of the complaints procedure in their room. No residents expressed any concerns during the inspection. The Protection of Vulnerable Adults (POVA) procedure needs to be amended to ensure it provides clear guidance for staff that it is not for the home to investigate any allegations. All allegations of abuse must be referred to Social Services. Staff spoken with confirmed that they recently attended POVA training and found this very informative. There have been no allegations of abuse made at the home since the last inspection. It was discussed with the registered Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 16 provider that he tries to locate local training in POVA that is designed for managers and provides more in depth information on their responsibilities. Marine View Rest Home DS0000014214.V288361.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25 & 26 “Quality of this outcome area is adequate. 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: Residents spoken with are happy with the environment and with their individual rooms. Rooms were seen to be personalised to reflect the individuals’ character and personality. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Residents must be able to independently mobilise to access rooms above the first floor. There is a stair lift available on one side of the building to the first floor, however there is one step that must still be negotiated to access the opposite of the building. One individual room was offensive smelling. The company responsible for steam cleaning the carpets called at the home on the day of the inspection to Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 18 apologise for the delay in getting the carpets cleaned. Due to staff shortages for the company, the homes steam cleaning programme was behind schedule. No requirement has been made in relation to this as action is being taken to address this issue. Radiators are unguarded and are not of guaranteed low surface temperature. Some have furniture placed front of them to avoid access to residents. The registered provider must ensure that any exposed hot water pipes are also covered. Not all pipe work was inspected. It was confirmed that there are risk assessments in place for the unguarded radiators. It was confirmed that hot water temperatures are checked every three months. This frequency needs to be increased to promote the health and safety for residents. One shower was noted to be dispensing water above the recommended 43°C. It was made an immediate requirement that all hot water outlets are adjusted to ensure water is delivered around 43°C. It should be noted that on the second day that the Inspector returned to the home, a plumber was visiting the home and has arranged to visit the home within the next two days to address this requirement. Staff remove the head of a tap for a bath when not in use to ensure that this hot water outlet is not accessed without supervision. There was a metal pipe sticking out of a wall in the lounge room. A chair had been placed over this. The registered provider confirmed that he will be installing CCTV cameras at the home. It was confirmed that this will be restricted to the entrances of the home for security and will not impose on the privacy of the residents residing at the home. The home was clean on the day of the inspection. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for communicable diseases and infection control. The content of these policies were not read. All resident surveys stated that the home was always fresh and clean. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents’ needs are being met with the number of staff on duty at all times, however suitable induction and foundation training must be provided to all new staff to demonstrate that staff are trained and competent to do their jobs. EVIDENCE: Staff confirmed that they are happy working at the home and residents were complimentary about the staff. Most staff have worked at the home for many years, which has provided consistency and continuity of care for the residents. Staff were observed to have a good professional rapport with residents. Eight resident surveys completed showed that there were always staff available when needed and one stated there are usually staff available when needed. Staff spoken with confirmed that there were always enough staff on duty. The rota provided to the Inspector demonstrates that there is generally two staff on duty during waking hours and is one carer works a waking night shift. There is someone on call at night if additional assistance is required. The residents residing at the home require minimal assistance from staff. Staff confirmed that due to previous staff leaving they have been at time short staffed, but have all assisted each other out to ensure that all needs of the residents continued to be met. The pre-inspection demonstrates that five out of eight care staff employed at the home have obtained their National Vocation Qualification (NVQ) level 2 in Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 20 care. A staff member spoken to confirmed that they will be undertaking their NVQ level 3 in care. Three staff files were inspected. There has been one new staff member employed since the last inspection and one is waiting for all recruitment checks to be returned prior to start commencing employment. The registered provider needs to ensure that references obtained identify in what capacity the referee has known the applicant. References, POVA check and a Criminal Record Bureau form had been obtained for the new staff member. The registered provider was reminded to ensure that all visiting professionals to the home that have unsupervised contact with residents have undertaken a POVA and CRB check eg, church representatives, hairdresser etc. Staff confirmed that they are kept up to date with all mandatory training, such as manual handling. One carer has just been appointed to ensure the health and safety within the home is maintained. Clearer records of training are being maintained and copies of training certificates were located in the files for each individual staff member. It was noted that staff that commenced employment at the home towards the end of 2005 have still not undertaken an induction programme. All staff must receive suitable induction training within six weeks of commencing employment and foundation training should be completed within six months of their employment, as per National Training Organisation (NTO) specifications. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 & 38 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” There is currently no registered manager at the home, however there are clear lines of responsibility with the home. A more structured quality assurance and quality monitoring system would enable management to assess the suitably of services provided at the home and identify areas that can be improved. EVIDENCE: The registered manager has recently left employment at the home. The registered provider is currently overseeing the management within the home and has applied to the CSCI to become the registered manager. The registered provider has owned the home for 15 years and has obtained his knowledge and skills in care throughout this period of owning the home. Staff are very complimentary about the registered provider and find him very supportive and approachable. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 22 The home undertakes a quality assurance survey with residents. The results of these are kept within an individual’s file. The results are not formally analysed, however action is taken to address any shortfalls identified. Additional areas to include in the quality assurance system were discussed with the registered provider eg, activities and food. Regular feedback should be sought from relatives/visiting health professionals and other stakeholders within the community on a regular basis. A structured 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 home does not hold any money for residents at the home. Residents either maintain their own finances or relatives will handle their financial affairs. The home did receive the personal allowance from one individual who required additional belongings to be purchased for him. The registered provider has been advised to ensure that receipts are kept of the additional purchases brought on the individual’s behalf. This is to safeguard the resident and the staff. It was confirmed that supervision has just been recommenced for all staff. There was evidence that staff were being supervised. The registered provider is undertaking the supervision for staff. It is required that those providing supervision are trained for this role. There were some fire doors noted not to be closing effectively. The self-closing devices on some of the doors were noted to have been released, therefore not allowing the doors to close effectively. It was not clear if staff or residents were removing the closing devices to ensure the door is not too heavy for residents to manoeuvre through. Any resident wishing their door to remain open, must have a proper fire door guard in place. It was made an immediate requirement that all fire doors remain closed unless suitable safety measures are in place. The pre-inspection questionnaire demonstrates that all relevant health and safety checks are undertaken and staff receive fire training and practice fire drills. The last fire drill was undertaken in March 2006. Some residents are capable of being involved and should be involved with the staff in regular fire drills. Any other health and safety shortfalls have been highlighted in the relevant section of the report. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 2 17 X 18 2 3 X X 3 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4, 5 & 6 Requirement That the Statement of Purpose and Service User Guide are updated, reflects actual practice and promotes confidentiality for current service users. That evidence be provided of service users/representatives input into the reviewing of care plans. (Timescale 30.11.05 not met) That risk assessments are undertaken and completed by an appropriately qualified person. That a policy and procedure is developed for when medication is taken home with the individual to ensure all medication provided and administered can be accounted for. That MAR charts clearly identify what medication is currently prescribed and administered for service users. That service users are provided with suitable and fulfilling activities. (Timescale 30.11.05 not met) That the complaints procedure includes a timescale in which DS0000014214.V288361.R01.S.doc Timescale for action 15/06/06 2. OP7 15 15/06/06 3. 4. OP7 OP9 13(4) 13(2) 15/06/06 30/06/06 5. OP9 13(2) 15/06/06 6. OP12 16(2) (m & n) 22(4) 15/06/06 7. OP16 15/06/06 Marine View Rest Home Version 5.2 Page 25 8. OP18 13(6) 9. OP25 13(4) 10. 11. OP25 OP30 13(4) 18(1) 12. OP33 24 13. 14. OP36 OP38 18(2) 23(4)(i) complaints will be dealt with. That the POVA procedure provides clear guidance for staff that it is not for the home to undertake any investigations. That all hot water taps dispense water around the recommended 43°C. (Immediate requirement) That radiators and pipe work are guarded or have guaranteed low temperature surfaces. That all staff receive induction and foundation training that complies with the NTO specifications. That a structured quality assurance and quality monitoring system is implemented that includes feedback from relatives, visiting health professionals and other stakeholders. That staff providing supervision are appropriately trained for this role. That all fire doors remain closed unless suitable safety measures are in place. (Immediate requirement) 15/06/06 19/05/06 30/08/06 30/06/06 31/07/06 30/06/06 28/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP2 OP3 OP7 OP12 Good Practice Recommendations That the registered provider retain a copy of the signed contract/terms and conditions for his own records That the information recorded at the pre assessments be expanded. That the care notes written on individuals be expanded. That the provision of activities be included in the quality assurance and quality monitoring process. (Outstanding DS0000014214.V288361.R01.S.doc Version 5.2 Page 26 Marine View Rest Home 5. 6. OP25 OP35 recommendation) That hot water temperature checks are undertaken at least monthly. That receipts are kept of the additional purchases brought on behalf of the service users. Marine View Rest Home DS0000014214.V288361.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Marine View Rest Home DS0000014214.V288361.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. 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