Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 23/06/05 for Markfield Court Care Centre

Also see our care home review for Markfield Court Care Centre for more information

This inspection was carried out on 23rd June 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A homely environment is provided which is appropriate to the categories of person accommodated. Staff are provided with training, which is relevant to residents needs. Residents are fully supported in maintaining spiritual needs, regular church services are held in the home.

What has improved since the last inspection?

The acting manager has developed a new system of team working. She stated that this would improve overall outcomes for residents, as they will all have named nurses, team leaders and key workers all of whom have specific measurable responsibilities. The new system had not been implemented at the time of the inspection however. Staff spoken with were aware of the new system and appeared to be confident that residents would benefit.

CARE HOMES FOR OLDER PEOPLE Markfield Court Ratby Lane Markfield Leicestershire LE67 9RN Lead Inspector Gill Adkin Unannounced 23 June 2005 9:30 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. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Markfield Court Address Ratby Lane Markfield Leicestershire LE67 9RN 01530 242595 01530 244287 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) Ashbourne Life Ltd Vacant Care home with nursing 85 Category(ies) of OP Old age (85 registration, with number PD(E) Physical disability - over 65 (85) of places Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To be able to admit the named person of category PD as identified in correspondence with the previous registration authority dated 5th July 2000 To be able to admit the named person in variation application number: 48891 of category DE (E) into the home. To be able to admit the named person as identified within variation application No. 52422 dated 7 August 2003 of category DE (E) within the home. Date of last inspection 14.02.05 Brief Description of the Service: Markfield Court is a care centre with provision for nursing and personal care. It is registered to accommodate up to eighty-five service users falling within Older Persons (OP) or Physical Disability (PD) Category over 65 years of age. The home is a traditional building which was formerly the nurses’ accommodation for the old Markfield hospital. It is located close to the A 50 and M1 junction 22 on the outskirts of Ratby and Markfield and is close to the towns of Coalville and Loughborough Leicestershire. It is easily accessed by public transport from the City of Leicester. The Care centre is an attractive and distinctive centre set in very large attractive and mature grounds of approximately five acres. The care centre has a custom designed woodland walk which is accessible to mobile service users.Grounds are mainly lawn and woodland and a retirement village, which has a bus service, further enhances the centre. Accommodation is located on three floors, which can be accessed by a shaft lift. The home has forty-five single bedrooms and twenty double bedrooms many are ensuiteand some open directly onto the garden. The home offers numerous lounges and dining rooms and specialised bathing facilities are available throughout the three floors of the home and it has access to the facilities of a social centre attached to it which is shared with the retirement village complex. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over two days and commenced at 9.30 am on 23/06/05.The inspection took 14.5 hours. The acting manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This inspection whilst being a statutory inspection was also undertaken as a result of a number of complaints received by the Commission for Social Care Inspection during the month prior to the inspection regarding management of the home, management of emergency procedures (fire) Staffing levels, cleanliness of the home and management of complaints by staff and residents. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the premises both internally and externally took place and the inspector viewed internal records, and care plans. The inspector spoke to residents, nurses, care and ancillary staff, and relatives. Discussions with the acting manager regarding requirements made at the last inspection indicated that most of the requirements made had been met. Three of the four recommendations made had been implemented. Comments were received from nine residents including those selected for case tracking. Additional comments made by residents about the service were mostly positive although a number of residents stated that things had changed significantly since the previous manager had left. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 6 Complaint findings: Management of the home: Inconclusive: Insufficient evidence was found to fully support this allegation. Management of emergency procedures (fire): Partially substantiated. Adequate evidence was found to support this allegation regarding fire procedure and poor response to fire evacuation by staff. No evidence was found to conclusively support the allegation regarding the manager’s involvement in this serious allegation. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 7 Staffing levels: Partially substantiated. Adequate numbers of care and trained staff were rostered on duty during this inspection. A larger than average number of staff had left their employment since January 2005 when the previous manager resigned. Evidence was found to support a variety of reasons for these staff leaving Markfield Court and indeed included three who resigned without reason. Domestic and maintenance staff numbers were also reduced during this time and this impacted on the cleanliness of the home and routine maintenance not being completed. Cleanliness of the home: Not substantiated On the day of inspection the home was found to be acceptably clean considering that they were reduced to using one vacuum cleaner and were awaiting the arrival of new equipment. The only concerns raised by residents were that pictures had been removed from corridors. Management of complaints by staff and residents: Partially substantiated. Although residents and staff were aware of the complaints procedure, residents tracked had not been issued with a copy of the procedure. A resident indicated that he would not make a complaint and would put up with things and staff felt that they were unable to take a complaint to the acting manager or senior managers as it would not be dealt with appropriately. Staff considered that the matters of concern to them would be better dealt with by the Commission rather than through internal procedure and hence complained anonymously. What the service does well: What has improved since the last inspection? Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 8 The acting manager has developed a new system of team working. She stated that this would improve overall outcomes for residents, as they will all have named nurses, team leaders and key workers all of whom have specific measurable responsibilities. The new system had not been implemented at the time of the inspection however. Staff spoken with were aware of the new system and appeared to be confident that residents would benefit. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 9 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 10 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 Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 11 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) 3.6 An inadequate assessment process results in residents needs not being fully met the outcome being that residents and their relatives are not confidant in the homes ability to manage care needs appropriately. EVIDENCE: The Commission for Social Care Inspection was involved in investigating a recent complaint regarding the care delivered to a respite resident. The outcomes of which were that the assessment process of the resident was inadequate to ensure that they received appropriate care as the home had failed to obtain a recent assessment of the person prior to admission. On this occasion of the three care plans tracked only one contained a full assessment and the care plan of a recently admitted resident contained neither an initial assessment or Community care assessment. It is acknowledged that some residents were assessed by the previous manager and it has been recommended that care plans contain all assessments undertaken prior to admission including those of external professionals to ensure that care plans produced are reflective of assessed needs. None of the resident’s case tracked were admitted to receive Intermediate care. The home does not currently provide Intermediate care. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 12 Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 13 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 Not all staff are adequately trained to an appropriate level to give medication safely, this may lead to errors being made and may put residents at risk. EVIDENCE: Requirements were made at the previous inspection regarding the quality and content of care plans. All of the three residents case tracked had a care plan in place, although some improvements had been made to care plans it was evident that additional work was required to ensure that all assessed needs were addressed and evaluated accurately and were reflective of outcomes for residents. Wound care regimes and delegated nursing task documentation such as the agreement to administer insulin was not fully documented in care plans and several risk assessments were out of date. Residents spoken with who had indicated on internal documentation that they wished to be involved in their care plans informed the inspector that the had not been kept informed and staff did not involve them in the evaluation of the plan. Medication systems and management were inspected and most areas inspected were adequately managed, medication records examined on the first and second floor were accurate and up to date, however records on the top Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 14 floor were incomplete and staff when questioned indicated that gaps on sheets were due to them having insufficient time to check them the previous day. None of the residents tracked were responsible for the self-administration of medication. Controlled drug stock was inspected and records /stock counted. All drugs were accurately maintained. Staff were questioned about the policy and procedure regarding management of errors and refusal of medication and all those involved were aware of the management process. Staff spoken with on the residential floor stated that they had undertaken recent distance learning training in medication administration although when questioned one member of staff was unaware of the what some of the drugs were for or the possible side effects. They were however aware of the management procedures for drug errors. Community nurses have given training to residential staff in the administration of insulin. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 15 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 choices and views are not taken into account this results in social and recreational interests and diet provided not meeting residents expectations. EVIDENCE: Residents case tracked were able to voice their opinions regarding the lifestyle they enjoyed and experienced in the home. Overall residents appeared to be happy and content with the systems and routines of the home and two residents commented that the acting manager regularly asks them “ how they are” Residents indicated that staff were usually very kind and considerate and that they were given choices regarding routines. Some residents expressed dissatisfaction with the quantity and quality of meals served and further discussion with the assistant cook identified areas for improvement (see recommendations) this was fully discussed with the acting manager. One resident commented that he and other residents were very unhappy that pictures had been removed from the corridors by domestic staff and was given the reason that this was due to the amount of time it took to clean them. When asked if they preferred them to be put back in place, residents all confirmed that pictures made the home less institutionalised. At the time of the last inspection the activities programme had been reduced due to the activities organiser being on long-term sick leave. Discussions with residents regarding the current programme indicated that although external entertainers Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 16 and trips were arranged the June activities programme included activities that only a limited number of residents could participate in (including bowls, tea dances, drinks in the bar) Many residents indicated that they were unable to go out on external trips and were not aware of or unable to attend the activities arranged due to their medical or physical conditions. A member of staff spoken with discussed the types of activities that she undertakes with residents. From discussion with residents it was indicated that their views and ideas regarding the current programme are not fully obtained or considered. The activities organiser was due to return to work full time shortly after this inspection when the current programme will be reviewed and will incorporate the resident’s views and ideas. Service users spoken with confirmed that their visitors were always made welcome and visiting was unrestricted. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 17 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) 16.18 Residents and staff are not confident in making complaints this may result in residents being vulnerable to abuse. EVIDENCE: Prior to this inspection the Commission for Social Care Inspection had received four anonymous complaints regarding the management of the home, management of emergency procedures (fire) Domestic staffing levels, cleanliness of the home and care practise issues. The Commission had also recently investigated a separate complaint from a relative regarding care practise. It was evident from this that the complaints procedure in place is accessible to staff and relatives. Residents spoken with during the inspection indicated that they would know who to make a complaint to but could not recall being given copies of the complaints procedure. One resident stated, “ I would rather put up with things than make a complaint” another stated that he had made complaints about the food but had not received a satisfactory response. Information from complaints received indicated that staff felt unable to make direct complaints to the manager for fear of reprisals. This was discussed with several staff members who confirmed that they would not complain as they did not feel confidant that their complaints would be handled satisfactorily by the acting manager or senior managers. A senior representative of the company who was in attendance at the inspection indicated that she had held staff meetings with senior staff but had not held similar meetings with other staff. It was agreed that this might be an ideal opportunity for staff to air their views and concerns. Discussions with residents and relatives and observation of staff at work indicated that residents are in the main treated respectfully.Robust adult Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 18 protection policies and procedures are in place, which are included in the initial induction and foundation programme for staff. Staff when questioned regarding reporting alleged abusive incidents were aware of the whistle blowing policy and “ the multi agency policy “ No Secrets”. A registered nurse and a care assistant both confirmed that they had received adult abuse training for which is undertaken six monthly by the training department. Training files inspected indicated that adult abuse training is not currently available for ancillary staff. Restraint training is not currenl on the training schedule and the acting manager agreed that this would be beneficial. The acting manager is aware of the vulnerable adult reporting procedure. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 19 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) 19.26 The home is clean, comfortable and meets residents needs. EVIDENCE: Complaints received by the Commission for Social Care Inspection included concerns regarding the cleanliness of the home and the maintenance of the fabric of the home. It was indicated that this was caused by lack of cleaning staff and lack of cleaning equipment. During the inspection, discussion with domestic staff confirmed that there was only one domestic type vacuum cleaner to cover all three floors of the home. Discussion with the acting manager identified that two vacuum cleaners had broken down together and that they were awaiting delivery of replacements. An inspection of the premises including individual rooms and communal areas bathrooms and toilets and also the exterior of the home identified that with the exception of some minor decoration and maintenance as agreed with the acting manager no areas of the home were considered sufficiently ill maintained to require enforcement action being taken. A number of bathrooms and one toilet required more thorough cleaning and an upstairs toilet required a repair to the flooring to ensure residents safety. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 20 All bedrooms and lounges were noted to be clean and well maintained. New carpets were being fitted to dining rooms during this inspection. Linen and curtains were noted to be in need of replacement in some areas. An inspection of the exterior of the home demonstrated that although the gardens at the rear of the home were in urgent need of grass cutting and general tidying sufficient areas were still available for residents to access the grounds albeit at the front of the home. Three residents were observed enjoying the morning sunshine and were seated on garden furniture near the entrance. The acting manager informed the inspector that the maintenance post had been vacant prior to the inspection. A new maintenance person had commenced work during the week of the inspection full time and an additional twelve hours of maintenance was being advertised. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27.29.30 The skill mix and numbers of care staff employed are able to meet the care needs of residents accommodated. Recruitment, selection and retention of staff does not ensure that residents receive a satisfactory service or are protected from harm. EVIDENCE: Staff spoken with during this inspection indicated that they were issued with copies of their job description, contract of employment and essential policies and procedures such as the grievance procedure and therefore were fully informed of the organisations procedures at the commencement of employment. Trained staff are employed on the two nursing floors and residential manager and care staff are employed on the top floor, which is residential. Discussions with the acting manager and senior nursing staff indicated that staffing levels are usually adequate to meet the needs of residents. Nursing staff indicated that they are occasionally called upon to monitor or give advice regarding residential clients and it was indicated that the acting manager is awaiting nursing determination by community nurses for a number of residents who are currently categorised as residential. Residential care staff are fully supported by the trained staff and a number of nurses are responsible for delivering internal training including induction. A senior sister stated that she is responsible for ensuring that new care staff complete a thorough basic induction. Records seen indicated that this includes personal hygiene. Complaints received by the Commission for Social Care Inspection indicated that large numbers of staff had left since the previous manager had retired. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 22 Observation of Internal records demonstrated that since February 2005.Twenty staff had either left or moved into other positions, three of which were resignations without reason/notice. Three of these positions were housekeeping which had left the home without an adequate number of staff at weekends. It was noted that only one domestic is employed at weekends to cover three floors this is considered inadequate considering the size and layout of the building. It was noted that agency cover for care and trained staff totalled 78 hours over a eight week period and therefore was not excessive when considering the size of the home. Staff training files were inspected and evidenced appropriate training provided by the organisation and internally by trained staff. Staff rosters inspected indicated that the home were currently meeting the agreed minimum staffing hours as per the previous registration authority guidelines. Three new staff employment files were inspected and it was noted that CRB disclosures were not contained within them. The acting manager confirmed that these are not currently stored in files and are kept in the administration office. It was advised that all CRB disclosures and POVA first checks should be kept in staff personnel files for inspection. None of the staff files contained photographic evidence and one file contained only one reference. It was noted that a volunteer working in the home did not have a current CRB disclosure in place. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31.32.33.36.37.38. The home is being run in the best interests of residents this ensures that their welfare is protected. EVIDENCE: Concerns as identified in the complaints received by the Commission for Social Care Inspection regarding the management of the home were found to be inconclusive as discussions with residents, staff and comments received on comment cards mostly indicated that the acting manager was approachable and appeared to have their best interests at heart. It was acknowledged that a change in leadership and management style might have been a contributory factor in staff making allegations regarding the new management style and subsequently staff resigning. Several staff commented on the new managers style and two of them indicated that staff “ hadn’t given the new manager a chance” and that she had Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 24 introduced some new systems which staff were in the process of getting used to It was apparent through discussion with residents that staff discontent was being filtered down to them and thus residents felt insecure with the new manager, although at least three of them stated that she was always available and always asks “how they are”. Several staff indicated that they considered the manager could be more transparent and visible on the floor and this was particularly apparent on the residential floor when staff considered the manager spent limited time with residential residents. The acting manager is fully supported by senior managers and internal documentation demonstrated that she has undertaken a robust induction and probationary period. Supervision records inspected indicated that the acting manager is required to be supervised by her line manager frequently. Comment cards from relatives indicated that they are happy with the current methods of communicating with them through meetings and rated staff including the new manager very highly. Concerns were raised prior to this inspection regarding the management of fire procedure following a fire alarm, which had been activated recently. It was indicated by staff and residents that the fire procedure had not been followed correctly and that action taken by the manager was dangerous and put them at risk. Discussion with the acting manager and a senior manager demonstrated that these actions had not been taken by the manager but by workmen on site. Following this incident consultation and inspection by the Fire officer on 05.05.05 took place and it was confirmed that a suitable and sufficient emergency action plan was not in place and that this had to be undertaken immediately and all staff retrained in evacuation techniques. The acting manager as part of an action plan stated that she has revised the drill policy and achieved 90 compliance in retraining of staff. Further concerns were raised over an unsafe technique used when moving and handling a resident, the matter was serious enough to require an immediate requirement notice to be issued. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 25 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 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 2 x STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 3 x x 3 3 1 Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 26 no 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 no38 Regulation 13 Requirement The registered provider must ensure that moving and handling technique used by staff is safe and appropriate and is in accordance with The Manual Handling Regulations 1992 The registered provider must ensure that staff files contain a CRB disclosure,POVA 1st check and proof of identity. CRB checks must be undertaken for all employees and volunteers. The registered provider must at all times ensure that suitable cleaning equipment is in place to ensure that the home remains adequately cleaned The registered provider must when considering the needs of residents ensure that ventilation is provided in all communal and individual rooms and is in full working order. The registered provider must provide a suitable number of domestic staff at weekends to ensure the cleanliness of the home. The registered provider must ensure that robust sytsems are put in place to ensure that C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Timescale for action Immediate 2. 29 19 Immediate 3. 19 23 By 13.08.05 4. 25 23 By 13.08.05 5. 27 18 By 13.08.05 6. 9 13 By 13.08.05 Page 27 Markfield Court Version 1.30 7. 16 22 8. 16 12(5)a medication is administered appropriately and signed for immediately after administration. The registered provider must issue all residents with a copy of the complaints procedure in a format which is understandable to them. The current system of reporting complaints by staff must be reviewed and improved to ensure that good personal and professional relationships are maintained. By 13.08.05 By 13.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard 3 7 7 7 8 9 12 Good Practice Recommendations The home should keep copies of delegated nursing task documentation in staff and resident files. residents care plans should evidence consultation with them or their representative wherever practicable Care plans should contain evidence of any initial assessments undertaken by the home or external professionals. Care plans should be reviewed immediately following discharge from hospital and staff made aware of any changes in care needs. Protocols as agreed with community nurses should be put in place and staff made aware of in relation to residents who are likely to have hyperglycaemic attacks. Robust systems should be put in place to ensure that staff are aware of the medicines that they are administering to residential clients and any possible side effects Appropriate measures should be put in place to ensure that activities provided are suitable and sufficient to meet residents needs.Further action should be taken to ensure that during periods of staff absence activities continue on a regular basis. Residents views should be considered when producing new menus and particularly in relation to provision of meals(salads) for residents who have chosen to reduce C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 28 8. 15 Markfield Court 9. 10. 11. 12. 13. 14. 19 19 25 30 24 27 weight. The garden areas should be kept sufficiently maintained to allow residents to access them freely.Maintenenace of gardens should be prioritisised in these areas. Decoration of the home should include attention to areas of peeling paint in bedrooms,corridors and communal areas. Routine discussion with residents will ensure that room temperatures are ambient and suitable to the needs of individuals. It is recommended that risk taking and restraint training are included in the staff training programme. It is recommended that an audit of bedlinen and curtains takes place and where considered necessary replacements are put in place. It is recommended that at least two cleaners are rostered on duty at weekends in order to adequately maintain the cleanliness of the home. Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 29 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicester LE19 1SX 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 Markfield Court C51 C01 S1917 Markfield Court V234375 230605 STAGE 4.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!