Inspection on 11/07/08 for Marion House

This inspection was carried out on 11th July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marion House 26/07/07

Marion House 27/06/06

Marion House 24/01/06

Marion House 20/06/05

Marion House 09/11/04

Marion House 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Marion House 40 The Avenue Moordown Bournemouth Dorset BH9 2UW Lead Inspector Tracey Cockburn Key Unannounced Inspection 11th July 2008 11:20 Marion House DS0000003961.V362961.R01.S.doc Version 5.2 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 Marion House DS0000003961.V362961.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 Adults 18-65. 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. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marion House Address 40 The Avenue Moordown Bournemouth Dorset BH9 2UW 01202 521985 01202 519002 manager.mhb@prospects-uk.org 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) Prospects for People with Learning Disabilities Mr Joe Halfpenny Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2007 Brief Description of the Service: Marion House is a large detached house in a quiet residential district of Bournemouth known as Moordown. The local area includes a wide range of shops, churches and community services, and is served by local bus services. The home accommodates up to eight adults of both sexes who have learning disabilities and some additional disabilities such as visual impairment. Each resident has their own bedroom; seven are on the first floor and the eighth on the ground floor. A Day Opportunities service is attached to the property but is separated from the care home by a locked door and has its own entrance at the rear of the property. The home comprises of a lounge, a dining room, a quiet room, a laundry and a kitchen. There are three bathrooms with toilets, three shower rooms with toilets, and two other separate toilets. Outside there are attractive grounds that include a fountain, sensory garden and pergola. The home is staffed 24 hours a day and there is a designated key worker and support key worker for each service user. PROSPECTS have been involved in the support of people with learning disabilities since 1975 and operate various services across the U.K. It is an organisation rooted in Christian principles and the ethos of the home reflects this. There is however no requirement for anyone to engage in religious activity whilst they are supported by PROSPECTS. The weekly fees are £750.00. For further information on fees and contracts the office of fair trading website is helpful: www.oft.gov.uk Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place unannounced over several days in different weeks. The inspection began at 11:20am on the first day. On the second day an expert by experience visited the home. We involve an expert in inspecting services so we can find out what staff and people living in the home think about the service. The expert brings their knowledge of using services and an understanding of what that can feel like to great effect in the questions they ask and what they observe during their visit. The expert by experience writes a report and parts of their report and observations will appear throughout the report and summary. The expert visited the home on the 15th July and spoke to 4 people who live there, as well as staff and the manager. A 3rd visit was made to the home and the main part of the visit was to undertake a short observational visit, this involved sitting in one place on this occasion this was the lounge and observing all the activities which took place between residents and staff. Further information on the tools we use to inform our inspections can be found on our website: www.csci.org.uk At the time of this inspection there are 8 people living in the home. Survey forms were returned from 5 people who use the service. Comments included: “not enough staff at the weekends” “lounge sometimes needs extra cleaning in the morning” 8 relatives, of people who use the service, returned survey forms. Comments included: “I couldn’t ask for better care and attention for my relative” “the one to one support is very good…it has been imaginative and carried out in an excellent way” “the recent turnover of staff has been difficult with the subsequent knowledge loss” “ we are very admiring of their standard of care” Survey forms were returned by 3 staff that work in the service. Comments included: “we have regular supervisory meetings also we see him (manager) on a daily basis.” “less staff turnover”: answer to the question “what could the service do better” “take more care to produce appetizing and nourishing food” in answer to the question “what could the service do better” A care manager returned a survey form. “The service at Marion House is person centred” Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 6 During the course of the inspection care records, staff files, training records, recruitment procedures, medication, quality assurance and health and safety records were seen. 4 people who use the service were spoken to and observed. The service returned the Annual Quality Assurance Assessment and this was used to assist with the planning of the site visit. What the service does well: What has improved since the last inspection? At the end of the inspection in July 2007 there were 4 requirements. At a random inspection in August 2007 made by the pharmacy inspector 1 requirement and 1 recommendation were made. The policies and practices within the home have improved; this means that people living in the home are safer. The registered manager has introduced weekly audits, which pick up any problems. A new policy has been introduced for staff on how to intervene to ensure that people are protected. The registered manager has also arranged for training in breakaway techniques for all staff. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 7 Staff are encouraged and supported to undertake national vocational qualifications which means that staff are receiving the training they need to do the job well. There is now a registered manager in post and the running of the home has improved. There is a quality assurance process in place and people are listened to and are part of the development of the service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who are considering this service would have their needs assessed before any decision was made about moving into the service. This means that they would know if the home could meet their needs or not. EVIDENCE: At this inspection there had been no new admissions to the home since the last inspection in 2007. The annual quality assurance assessment states that the home would like to have “More involvement from the people already in residence in running Marion House including whether they feel someone should live there.” The annual quality assurance assessment also states what they would do as part of the assessment process. • Visits prior to admission, short stays for meals etc and overnight stays are all encouraged as part of the assessment process allowing potential service users to meet staff and existing service users. • Each prospective person is given a copy of the statement of purpose and a service users’ guide in easy to read format. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 10 On the 2 files looked at there was evidence of care management assessments and that care plans had been developed from this documentation. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live in the service have individual plans of their care needs. This means that everyone has a clear understanding of how each individual likes and needs to be supported. People who live in the service are supported to make decisions about their daily lives and risk assessments support the lifestyle they want. To ensure consistency reviews have to take place according to the homes own guidance. EVIDENCE: The annual quality assurance assessment completed by the manager states that they do the following in regard to care planning and risk assessments. • From AQAA: The Principle of Personal Value (PPV) is guiding value to all we do – including individuality, integrity, dignity, independence, inclusion and spirituality. • We encourage the people we support to express what they want in their lives and how they want to live their lives. This is incorporated into their Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 12 Essential Lifestyle plan (ELP), • Each person supported has a key worker and meets with them regularly. • Services users have up to date risk assessments with actions to minimise identified risks and hazards. To support service users to review and update their ELPs. To go through the ELP’s at team meetings. • To run a training course to teach service users how to interview and select under an equal opportunities framework. 2 care files were seen as part of the inspection and they contained detailed information on the needs and goals or each person. The service has a number of documents that they use which contains information on personal and healthcare needs, there is an ‘all about me’ file and an Essential Lifestyle Plan. These files detail how individual’s want and need to be supported and are written from their perspective. The plans are clearly put together with the involvement of the individual and people who know them well such as family, friends and advocates. Each file also contains a ‘quality of life’ monitoring form, which the guidance and annual quality assurance assessment says should be completed monthly. This was not done every month in the files seen. This form is a review of monthly activities, progress towards goals and wishes for the coming month. People who live in the home are involved in advocacy services with at least 1 person on the committee of the local advocacy group. People spoken to say that they are able to make choices in their daily lives about issues, which are important to them and their ‘all about me’ files, demonstrated this. The annual quality assurance assessment written by the manager states: “To write risk assessments on an ongoing basis to enable service users support to adapt and change according to their needs and choices.” Risk assessments were seen on the 2 files. They were reviewed and there was detailed information on how to ensure that both the individual and the member of staff were protected. In the annual quality assurance assessment it states that: “Service users have become more involved in, daily living skills such as cooking cleaning laundry and taking ownership of their home. Service users have become more involved with their finances with them all having individual support and guidelines following on from choices that they have made.” Risk assessments have been updated to cover these areas. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live in the service are able to participate in activities, which interest them in the local community. They have relationships with the people they want to and their rights are respected. People who live in this service are offered a healthy diet. EVIDENCE: The annual quality assurance assessment from the service states: We provide and facilitate many activities both inside and outside their home. • We ensure that the people we support get the opportunity to take part in activities that are for those without a disability. • Service users are encouraged to get involved with the local community whenever possible. • Contact with and involvement by family and friends is encouraged. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 14 • Employment and training opportunities are explored and support given. Service users are supported to take part in all the routine tasks of their home, including planning and preparing meals.” The assessment states that plans for the next 12 months include: “To support service users to review and update their ELPs linking in with their reviews with clear targets regarding their dreams and aspirations. Service users with support will have the responsibility of deciding what they would like to cook for them selves and the other service users and for staff to promote a range of well balanced and healthy foods and meals.” The expert found that many of the people living in the home attend the day centre in the back garden where they participate in activities such as arts and crafts. The expert also found that people are supported to go out on 1:1 shopping trips or to the cinema or the gym. 1 person told the expert that they like trampolining and that staff found someone for them to do this. People told the expert that at weekends they go to church if they want to. People said that they go on holiday and can choose where they go. 1 person who lives at Marion House is on the committee of a local speaking up group. People told the expert that they are able to choose the food they want and can have something else if they don’t like what is on the menu. People living in the home tell us that they attend residents meetings were they discuss what activities they want to do and what holidays they want to go on. The minutes for one meeting were seen. The meeting was dated 15/06/08. They not only discussed what they wanted to have on menus but also what they would like to do if it was their birthday. They also discussed a new member of staff and that they were happy with the new notice board which contained information on who lives in the home (with photos) as well as information about the people who work in the home and who was working each day, also with photos. People were also asked their opinion on decorators coming into the home and the relatives of someone who was leaving came to explain this to the other people living in the home. The quality of life monitoring form for 1 person stated that the member of staff would try to organise some days for a holiday but that it depended on staffing. There was no evidence that this holiday took place. There was evidence in 2 files seen that people are able to participate in activities which interest them such as swimming. There was also evidence in the 2 files that people are being supported to use public transport by applying for bus passes. The 2 ‘all about me’ files seen contain information on how people like to be supported, when they want to get up, when they choose to go to bed. How they have a different routine depending on what they are doing each day. 5 Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 15 people who returned survey forms said they were able to make choices about their daily lives. 1 person who responded said that they can’t always do what they want at the weekend and another said there wasn’t enough staff at the weekend to do what they wanted to do. The annual quality assurance assessment submitted would suggest that the manager is aware of the need for more 1:1 time so that people can participate in individual activities. People living at Marion House are responsible for household tasks and during the last residents meeting they discussed how they could support each other with those tasks. People are asked what they would like to see on the menus and these ideas are used. 1 member of staff who responded to the survey said that the home needed to be better at encouraging and producing healthy meals. During the inspection people were observed making hot drinks for themselves and during the observational visit 1 person was encouraged to drink a fruit smoothie. He said it was “really good”. An action point from the residents meeting on 06/05/08 was to ‘get a menu book’. In 1 file seen the person’s weight was being recorded monthly but there was no link to a nutritional assessment. The fridge contained cooked chicken covered in cling film but there was not date on the item to say when it had been cooked. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live in this service receive support in the way they prefer and have their physical and emotional needs addressed. The home has a policy and procedure for the safe handling of medication, which protects the people living in the home. EVIDENCE: 2 files were looked at both contained information on how each person likes and needs to be supported with tasks such as hair washing, getting up, choosing the clothes to wear. There was also information on how they like to be spoken to what they don’t like such as people shouting and what time they like to be woken in the morning. There was also information on any specialist advice such as any medical condition they might have and what this meant in terms of how staff should support them in their daily life. Survey forms returned by both staff and relatives expressed concern over the Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 17 number of staff who have left and how this might have affected the consistency of support being provided. Both of the files seen contained information and the action being taken; as a result of any health care appointments at the dentists or audiologist or the optician. There was also evidence of staff noticing issues such as redness of skin and seeking medical appointments with the GP and the action taken as a result. The annual quality assurance assessment completed by the manager states: “All staff who administers medication have received medication training and have passed an internal assessment. Good medication records are kept to facilitate an accurate audit trail.” Ongoing communication with service user, family and health professionals regarding health needs Plans for the next 12 months: To review service users “home remedies” and make sure that they are all authorised by their GP. • To identity potential service users who are able to self medicate and support them to be able to do this. To work alongside the GP to reduce the term “as directed” on the MAR sheet and to have clear additional guidelines for every medication with the term “as required”. At the random inspection in August 2007 there was a requirement and a recommendation made regarding medication. It was found at this inspection that both the requirement and the recommendation were met. The new manager has introduced a system for monitoring and auditing records on a weekly basis. The task has been delegated to the deputy manager, who audits the records every Monday. The medication policy has been updated and the manager undertakes 3 monthly spot checks of the records. No gaps on the medicine administration records were found. All medication is stored correctly and securely. All staff that are handling medication have received Boots accredited training. Each person living in the home has a medication cupboard in his or her own bedroom. There is a record of each member of staff’s signature on the file. Each person has a medication profile, which includes information on the reason for the medication, possible side effects and what to do if any medication is missed. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints system, which means that people who live in the service can be confident that their views are acted upon appropriately. Safeguarding training for staff means people are protected from abuse. EVIDENCE: The home has a complaints log. At this inspection it contained only 1 complaint for 2008. The annual quality assurance assessment states: • To have all the different local authorities Adult Protection Polices that funds the service users. • Service users to always have the chance to make a complaint in house meeting and monthly key worker meetings. • To record positive feedback, informal complaints as well as formal complaints. Staff to have training on what a complaint is and how to record them The survey forms returned by people who use the service indicates that they are aware of how to complain and who to speak to. Staff who returned survey forms said they were aware of the action they needed to take if any one raised a concern. 1 concern which was raised by someone living in the home involved concern over shouting at night a solution was suggested which the person said they would try but there was nothing written down about whether or not this solution was successful. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 19 All staff are up to date with safeguarding adults training and there is a policy in the home. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People live in a homely and comfortable environment, which they see as home and take pride in. The home is clean. EVIDENCE: The annual quality assurance assessment states: • We now have an ongoing refurbishment plan and to prioritise refurbishment needs within the budget constraints. • Fixed outstanding maintenance problems including broken shower, loose skirting board, bathroom fans and redecoration of hallway. A shift plan that includes specific cleaning tasks at certain times of the day. • What we could do better (AQAA) To modernise the furniture and fittings of Marion House.” Some areas of the house are not always kept clean.” Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 21 The service development plan for the home dated November 2007 – April 2008 states that they are planning to buy new pictures for the home as well as new lampshades and curtain rails. The expert thought the home was clean and tidy but could be made to feel more homely. Although the expert did say that there are photos of the residents around the home. During the inspection the manager said that they have decorated the hall and changed the carpet. People said that they like their rooms and are able to have their personal belongings around them. During the observation visit to the home 1 person had chosen fresh flowers to put in their room and a member of staff supported them to put them in a vase and take them to their room. The small laundry room is cluttered and paintwork is peeling which means that the walls would not be easy to clean. At the time of the inspection 1 of the washing machines was not working. The cupboard containing hazardous substances was locked however there is not door to the laundry room. There are hand-washing facilities available. The home has policies and procedures in place regarding infection control and staff have received training. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A dedicated staff team supports people who live in the service. The recruitment process has improved and people who live in the service are protected by the practice in place. Training has to be linked to the needs of the people in the service to ensure their needs are fully met. EVIDENCE: The annual quality assurance assessment states: • There is a detailed staff training plan and relevant internal and external training is being provided. • 6 staff are working towards NVQ • Improvements in the recruitment and selection process. Starting a relief bank and having consistent agency workers when needed to cover shifts. Improvements planned in next 12 months: To run a training course to teach service users how to interview and select under an equal opportunities framework. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 23 To review and update induction process including relief and agency workers. Need for Staff to have supervisions every six weeks. • Clear interview, reference and CRB process. • Prospects encourage staff to obtain relevant qualifications. • Staff receive on-going training from both internal and external sources. • All staff have recorded supervisions and annual appraisals. • Training plans are set and are worked towards • There are effective lines of communication and regular senior staff meetings. Staff have fortnightly team meetings. The expert spoke with some staff that work in the home, 1 person said that there had been a big improvement in the past year. There were new systems in place and the person felt really supported. Another member of staff told the expert that people living in the home had good lifestyle choices. The file for 1 new member of staff was seen and this contained detailed information on how they were recruited including 2 references, interview questions and answers, application form and identity checks. The criminal records bureau check was returned before they started work in the home. An external trainer provides induction training. There is evidence that staff are working toward their national Vocational Qualifications and that other training is taking place with regard to restraint. No evidence of total communication training. Staff were observed through out the inspection talking to people who live in the home and discussing what activities they may want to do or just supporting them when they were unhappy or upset. People who returned survey forms said that there had been a lot of changes of staff. They also said that staff were helpful and kind. • Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service has a registered manager which means that the people living and working in the home benefit from someone with skills and experience being in charge. People living in the home should be confident that they are listened to and their views form part of the homes development. Systems in place ensure that the health, welfare and safety of people both living and working in the home are protected. EVIDENCE: The annual quality assurance assessment states: • To include actions from audits and “family questionnaire” into the development plan. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 25 To develop a service user survey in accessible formats which feeds into the development plan. Review of the health and safety procedures within Marion House ensuring they meet all relevant legislation and allocating member of staff to carry out checks. To have support worker as named health and safety person and carry out monthly checks. The experts spoke with the manager who explained the Christian ethos of the home and how people do not need to be a Christian to live here but would need to feel comfortable living with Christians and being supported by Christian staff. The manager started working in the home in September 2007 and is now registered with the commission. There is s service development plan for the home and the manager has introduced systems to ensure that activities such as giving medication are audited weekly. Tasks have also been delegated to senior members of staff and work has been done to develop a training programme. There are 6 monthly management review meetings and a quality audit was completed in February 2008 with a conclusion and an action plan. The review in April identified the action still outstanding and the reason why with revised target dates. At the medication audit done at the same time as part of the overall audit 6 staff were assessed and were 100 accurate. Regulation 26 visits are being done monthly with the last visit on 10/06/08 this was undertaken by the regional director. Staff are up to date with all mandatory training. The fire records were up to date. There was evidence that equipment has been serviced when necessary and all portable appliances were checked. • Marion House DS0000003961.V362961.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(2) (b) Requirement The registered manager must ensure that the monthly reviews of service user’s care plans are consistently reviewed and goals implemented in accordance with the homes own guidance. Timescale for action 31/10/08 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 YA17 YA17 YA22 YA30 Good Practice Recommendations The registered manager should ensure that any food stored in the fridge has the date it was cooked clearly labelled on it. The registered manager should ensure that when recording the weight of an individual this is linked to a nutritional assessment. The registered manager should ensure that any complaints and concerns are followed up so that any action taken can be reviewed to see if it is working. The registered manager should ensure that the paintwork, which is flaking, in the laundry room is redecorated so that the walls are easy to clean. Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Marion House DS0000003961.V362961.R01.S.doc Version 5.2 Page 29 - 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!