CARE HOMES FOR OLDER PEOPLE
Marlborough Lodge 83/84 London Road Marlborough Wiltshire SN8 2AN Lead Inspector
Elaine Barber Key Unannounced Inspection 10:10 31st January 2007 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 Marlborough Lodge DS0000028337.V323175.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. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Marlborough Lodge Address 83/84 London Road Marlborough Wiltshire SN8 2AN 01672 512288 F/P01672 512288 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) Susan Lesley Harper David Llewellyn Harper Susan Lesley Harper Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Marlborough Lodge is a private care home offering accommodation and personal care to 18 older people. Marlborough Lodge is two Victorian houses, which have been made into one building. The home is situated on the A4, Marlborough to Hungerford Road on the outskirts of Marlborough, and is just ten to fifteen minutes walk or two minutes drive from the town centre. A bus service to the town centre passes the home and the bus stop is nearby. The home provides ten single and four shared bedrooms. Two bedrooms have en-suite facilities. The shared bedrooms are used as singles and would only be used as a shared room for people who chose to move in together such as friends or couples. There is a large lounge and a large dining room with some additional comfortable chairs. There is a small front garden and a larger back garden together with adequate parking facilities. The fees are between £390 and £600 a week. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home. During the visit information was gathered using: • • • • • • Observation Discussion with people who lived in the home Discussion with relatives Discussion with staff Discussion with the manager and deputy Reading records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • Comment cards were received from eight people who lived in the home. Comment cards were received from six relatives. Comment cards were received from seven staff. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the visit. What the service does well:
Each person had a contract and a statement of their terms and conditions with the home to safeguard their interests. Their needs were fully assessed to ensure that all their needs would be met. People’s health, personal and social care needs were set out in their individual plans to ensure that their needs would be met. Each person had an individual plan and a record of the outcomes that they wished to achieve from living in the home. Risks were assessed and action was identified to manage any risks. Each person also had a manual handling assessment to ensure they were assisted appropriately. People said that their personal and medical needs were being met. Relatives and staff said that the standard of care was very high. One person who lived in the home said ‘I am happy and comfortable’ and another said ‘Very good’. People found that the lifestyle in the home matched their expectations and needs. There was a range of activities and outings to suit individual preferences. People maintained contact with their family and friends and the local community as they wished. Two visitors said that they were welcome in the home at any time. People could exercise personal autonomy and choice. People were all treated as individuals and were very much themselves. People
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 6 had a varied, appealing and balanced diet. Most people said that the food was very good. Comments included ‘Lovely, very good’, ‘I have never had a meal I cannot eat’ and ‘Exceptional’. There was a complaints procedure and people knew how to make a complaint. People were confident that their complaints would be listened to, taken seriously and acted upon. There was a procedure about protecting people from abuse and staff had received training about prevention of abuse. Staff were aware of the abuse procedures so that people were protected from abuse. People lived in a safe, well-maintained environment with access to comfortable indoor and outdoor communal facilities. There was a large lounge and another large lounge dining area. The accommodation was well decorated. There were two bathrooms, one on each floor and people had wash basins in their rooms. People had sufficient and suitable toilets and washing facilities and there were sufficient bathrooms to meet their needs. There was a separate laundry room with a washing machine and tumble drier and a separate sluice. People said that the home was always fresh and clean. The home was clean, pleasant and hygienic. There were usually three care staff on duty. The manager had recently raised the staffing levels to meet people’s changing needs. People’s needs were being met by sufficient staff with an appropriate mix of skills. There was a range of training and some staff had National Vocational Qualifications (NVQ). Other staff were working towards NVQ. People were supported by staff who were trained, qualified and competent to do their jobs. People made positive comments about the staff including ‘They do try to be there at all times’, ‘anybody in trouble they are always there’, ‘most helpful’, ‘very good’, ‘they try to please in every way’ and ‘(there) whenever I need them’. The home was run and managed by the manager and care manager. Both were appropriately qualified and had sufficient experience so that people benefited from living in a well run home. One relative said in their comment card, ‘This is an outstandingly efficient and friendly home’. The manager conducted surveys of people’s views about the home and developed a plan to make improvements. People’s views underpinned all quality assurance and improvement so that the home was run in people’s best interests. A member of staff said ‘Good atmosphere and take residents’ wishes into account so provide well for day to day comfort and happiness.’ Some people managed their own money and had a lockable storage space to keep it. Staff helped other people to manage small amounts for money and kept records of deposits and withdrawals. People’s financial interests were safeguarded. There were health and safety policies and regular health and safety and fire safety checks were made. Equipment was serviced and staff had relevant
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 7 training. The health, safety and welfare of the people who lived in the home and the staff were generally promoted and protected. What has improved since the last inspection? 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. Marlborough Lodge DS0000028337.V323175.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 Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person had a contract and a statement of their terms and conditions with the home to safeguard their interests. Each person’s needs were fully assessed to ensure that all their needs would be met. The home did not provide intermediate care. EVIDENCE: The records of three people were seen. Each had a contract which included their terms and conditions and fees. Those people whose care was paid for by Social Services also had a contract between Social Services, themselves and the home.
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 10 One of the people had been admitted to the home before there was a requirement that people must have an assessment. They had up to date information about their needs in their care plan. The other two people had their needs assessed when they moved into the home. Both had an assessment completed by staff in the home and one had an assessment from a social worker in the community team. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs were set out in their individual plans to ensure that their needs would be met. Their health care needs were being met. People were protected by the home’s policies and procedures for dealing with medicines. People felt that they were treated with dignity and respect and their right to privacy was upheld. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 12 EVIDENCE: The records of three people were read. Each person had a detailed care plan covering their personal, health and social care needs. The plans included the aims and outcomes people wished to achieve. The key workers reviewed the plans once a month. However the plans were not signed by the people or their representatives to show that they had been involved in developing them and were in agreement with them. The people who completed comment cards said that they always received all the help that they needed. Two relatives who were spoken to said that they were very happy with the care provided and the care was very good. Each person’s health care needs were included in their plans. They were all registered with a GP and saw the GP and district nurse when needed. Nursing care and advice about pressure areas was provided by the district nurse who provided any equipment needed. The continence advisor also provided advice. The community mental health team monitored psychological health and provided care when needed. People had risk assessments in relation to falls and pressure areas and appropriate interventions were identified in their care notes. There were opportunities for exercise. People also had manual handling assessments. Nutritional screening formed part of the assessment and a record was kept of nutrition and weight. Some people were having nutritional supplements. One person had received advice from the speech and language therapist. The GP referred people who required hearing tests and they attended the local hospital. Appointments with health care professionals were recorded in the daily records. People said that they saw the dentist, chiropodist and optician and there were also records of these visits. All the people who completed comment cards said that they always received the medical support that they needed. There was a medication policy and the home used a monitored dosage system. There was a record of each person’s medication in their care plan. Records were also kept of medication received into the home, administered to people, returned to the pharmacist and destroyed on a medication administration sheet (MAR). These were mostly in order but on one occasion a member of staff had not signed the record. The deputy checked the medication and found that it had been given. She said that she would take up the matter with the member of staff concerned. Medication was appropriately stored and there was a controlled drugs cupboard and a controlled drugs register was available when required. Staff who administered medication had received training. The pharmacist provided advice. Staff monitored the condition of people on medication and referred them to the GP if needed. People who were able could look after their own medication. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 13 Staff gave attention to maintaining people’s privacy and dignity. Each person had their own bedroom. There were signs on each door with the person’s name and the word ‘Private’. Staff knocked on people’s bedroom doors before entering. People had medical examinations in the privacy of their rooms. People could choose who and where to see any visitors, including in the privacy of their rooms. People had access to a mobile phone, which they could use in the privacy of their bedrooms and they were not charged for any calls. People could also have a telephone installed in their rooms and some had their own phones. People’s mail was given to them unopened, although staff would help people to read their mail if asked. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14,15 Quality in this outcome area is good and some aspects were excellent. This judgement has been made using available evidence including a visit to this service. People find that the lifestyle in the home matches their expectations and needs. People maintain contact with their family and friends and the local community as they wish. People can exercise personal autonomy and choice and they receive a varied, appealing and balanced diet. EVIDENCE: Routines were flexible and fitted in with people’s wishes. People’s preferences for social, cultural, religious and recreational activities were recorded in the assessments and care plans. People said that there were regular activities. There was a range of activities to meet individual preferences. These included going to church, a church service in the home once a month, visits to the theatre and garden centres, board games, walks, puzzles, TV and video. On the day of the inspection there was singing in the lounge after lunch. Three
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 15 people who completed comment cards said that there were always activities that they took part in and four said that there usually were. Comments included ‘We go to the theatre and exercise games are arranged’, ‘On the whole the activities are very good. I go out when I want and when anything is arranged. Play ball games’, ‘I enjoy the outings’ and ‘I am very happy and we have a lot of fun. People are willing to talk and play cards’. People’s preferences for social contact were recorded in their assessments and care plans. People said that they had visitors who could call at any time. Two visitors said that they were welcome in the home at any time. People talked about visits from their relatives and going out with them. One person was expecting a visit from their son that afternoon. Observations and discussions with people confirmed that they could make many decisions without reference to staff and this included what to wear, when to get up or go to bed. People had brought items of their furniture and personal possessions to make their bedrooms more homely. They could choose how and where to spend their time, where to eat, and what activities to participate in. One person said that they used to go out everyday independently to collect their newspaper but they were no longer able to do so. Areas where people were expected to refer to staff included going out unescorted, bathing and support with their personal and health care arrangements where assistance was required. The policy of the home was to give a bath when requested. The home would manage people’s personal spending if there is no one able and willing to do this and if the residents request assistance. It was clear during the inspection that people were all treated as individuals. An independent person had assisted people to complete comment cards so that their views would be representative. There was a satisfactory and varied menu. The menu provided a choice at breakfast and teatime with a set main meal at lunchtime. However, alternatives were provided if someone did not like the meal offered. At lunch people said that the food was very good. One person was having mince as they did not like pork, which was on the menu. Special diets were catered for. Drinks and snacks were also available throughout the day and night. People tended to eat their lunch and tea in the dining area although they could choose to eat all their meals in their bedrooms or the lounge. On the day of inspection the food was well cooked and well presented. Two people said in their comment cards that they usually liked the meals. Six people said that they always liked the meals. Comments included ‘Lovely, very good’, ‘I have never had a meal I cannot eat’, ‘we have very good food and very nicely served’ and ‘Exceptional’. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were confident that their complaints would be listened to, taken seriously and acted upon. People were protected from abuse. EVIDENCE: People were provided with a booklet about the complaints procedure. The procedure specified that complaints would be responded to within 28 days and included information about referring a complaint to the CSCI at any stage. There had been no complaints since the last inspection. A requirement was made at the last inspection that outcomes to each aspect of a complaint must be recorded. This had been addressed and the outcomes of a previous complaint had been recorded. People who were spoken to commented that they had no complaints or concerns. However, if they did have any, they felt confident in discussing them with the manager and staff who would listen and deal with them appropriately. The people who completed comment cards said that they knew how to make a complaint. Four out of six relatives who completed comment cards said that they knew about the complaints procedure.
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 17 There was a policy about prevention of abuse and a procedure for dealing with allegations of abuse. There was also information for staff about ‘No Secrets’. Allegations of abuse were followed up promptly, action was taken and recorded. A previous incident had been dealt with appropriately in line with policy and procedures. Prevention of abuse was covered in induction and probation meetings. Most staff had had training about abuse of older people. One member of staff had done a protection of vulnerable adults course and there was a plan for further training for all staff. Four staff who completed comment cards said that they were aware of the adult protection procedures. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lived in a safe, well-maintained environment with access to comfortable indoor and outdoor communal facilities. People had sufficient and suitable toilets and washing facilities and there were sufficient bathrooms to meet their needs. The home was clean, pleasant and hygienic. EVIDENCE: The house is in keeping with others in the road. There is a planned schedule of maintenance and renewal. The garden was kept tidy and was accessible. Some people said that they sat out in the garden in summer. The furniture in the communal areas was domestic in style and homely. There was no CCTV.
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 19 The home met the requirements of the Environmental Health Officer and fire officer. The combined communal space consisted of a lounge/dining area and separate spacious lounge, which provided suitable space in excess of the national minimum standard of 4.1 square metres for each person. These rooms provided a choice of where to sit and were suitably decorated and furnished. However there was no communal space where service users could receive visitors in private. There was a combination of domestic style artificial lighting and natural lighting. There were sufficient bathroom and toilets facilities to meet people’s needs. The home provided two bathrooms: one on each floor. One had been modified the previous year to provide a walk-in bath. The home was clean, tidy, comfortable and free from offensive odours. The laundry room was on the ground floor. It had an industrial washing machine and tumble dryer, which were sufficient to meet the needs of people in the home. A laundress was employed five days a week to undertake the washing and ironing duties and the care staff also assisted with this task. People’s clothing was labelled or colour coded to ensure that garments were appropriately returned to them. The sluice was in the laundry room and there were infection control procedures. All the people who completed comment cards said that the home was always fresh and clean. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is generally good although some attention was needed to recruitment practices. This judgement has been made using available evidence including a visit to this service. People’s needs were being met by sufficient staff with an appropriate mix of skills. People were supported by staff who were trained, qualified and competent to do their jobs. People were not fully protected by the home’s recruitment policies and practices. EVIDENCE: There was a minimum of three members of care staff and on duty throughout the waking day. The manager said that she had increased the number of staff because of the changing needs of some of the people. Additional care hours were deployed when there were activities. On the day of inspection there were exercises in the afternoon. In addition to the care staff there were the owner/manager, the deputy, cooks, laundress and a housekeeper. There was one waking night staff on duty each night and a member of staff sleeping in. People said that the staff were very caring, they anticipate their needs and are
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 21 responsive. One person said that the staff were kind. One relative who completed a comment card said ‘Have always found the staff helpful and friendly to myself and the residents’. All the people who completed comment cards said that the staff listen and act upon what they say. Five of these people said that the staff are always available when they need them and three said that they are usually available. Other comments included, ‘They do try to be there at all times’, ‘anybody in trouble they are always there’, ‘most helpful’, ‘very good’, ‘they try to please in every way’, ‘(there) whenever I need them’, ‘the staff are very tolerant’, and ‘generally speaking the staff do everything they can for me’. There were sixteen senior carers and two juniors plus a care manager and deputy care manager. Five care staff had National vocational qualification (NVQ) Level 2, and one had NVQ Level 3. Four staff were working towards NVQ Level 2 and two were working towards Level 3. The care manager had the registered managers award and the NVQ assessors’ award and was a qualified trainer in moving and handling. The manager said that several staff had completed NVQ Level 2 and then left to work elsewhere. New staff had induction training. There was a range of other training including food hygiene, manual handling, health and safety, first aid, fire instruction, abuse of older people, safe handling of medication and dealing with difficult situations. Four staff who completed comment cards said that they were given time and funding for relevant training. There was a recruitment procedure. New staff completed an application form, were interviewed and checks and references were taken up. Records were kept of the interviews. New staff completed a health questionnaire and declarations that they were physically and mentally fit and they had no convictions. The records of three new staff were seen. One member of staff had been recruited by an agency. The agency provided two written references. However neither was from the most recent employer so the manager had sent off for this reference. The manager said that she had thought that the agency had done the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks but they had not and the person started work before these were received. The manager said that the person worked on general tasks until their POVA first check was received. The second member of staff had started work following a POVA first check and one written reference. The manager had spoken to the second referee on the phone and they were going to send a reference. The third member of staff had two written references before they started work. They worked for one night with the manager before their POVA first check and CRB check was received. The manager had taken measures to ensure that the staff were supervised and worked safely before their checks were received. However, two written references and a POVA first check must be obtained before a member of staff starts work with people. They must also be supervised until their CRB check is received. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 22 New staff were only confirmed in post following a satisfactory CRB and POVA check. New recruits were given copies of the staff handbook and General Social Care Council code of conduct and practice. All staff received a statement of their terms and conditions. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run and managed by people who were appropriately qualified and have sufficient experience so that people benefited from living in a well run home. People’s views underpinned all quality assurance and improvement so that the home was run in people’s best interests. People’s financial interests were safeguarded. The health, safety and welfare of the people who lived in the home and the staff were promoted and protected, apart from some attention, which was needed to the fire instruction for staff.
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 24 EVIDENCE: The owner, who was also the manager, had appropriate management and supervisory experience and she had overall responsibility for the management of the home. She had a CSS (Certificate in Social Services) qualification and had also achieved the NVQ level 5 in Management as well as being a NVQ Assessor. She was supported by a care manager who had day to day responsibility for the care of the residents. The care manager had a SEN nursing qualification and had also obtained the registered managers award and the NVQ assessors’ award. She was also a qualified trainer in moving and handling. The manager had recently returned to work following a period of illness. While she was away the care manager, who also had appropriate qualifications and experience, managed the home. One relative said in their comment card, ‘This is an outstandingly efficient and friendly home. We are always consulted and kept in touch. Nothing is too much trouble. I have every faith in’ the care manager and manager. Another relative said ‘I have nothing but praise for Sue Harper and her staff. They have provided first class care.’ A third relative said ‘The home seems very happy’. One member of staff said in their comment card, ‘Management are friendly and supportive’, another said ‘The management is friendly and supportive and easy to approach’. A third member of staff said ‘Good atmosphere and take residents’ wishes into account so provide well for day to day comfort and happiness.’ The policy of the home was for people to manage their own money or appoint an appointee to do so on their behalf. The staff helped some people to manage their personal money and records were kept of withdrawals. Four of these records were seen and they were accurate. A requirement was made at the previous inspection that the registered person must make an audit of people’s finances. The manager and the deputy were now auditing the finances once a month to ensure that they were managed appropriately. Everyone had been provided with lockable storage within their bedrooms to keep their money secure. The home had a detailed quality assurance system. This included surveys of people who used the service, staff, professionals who had contact with people and regular visitors. Surveys had been sent out in the last twelve months. The manager looked at some aspects of care on a monthly basis. The manager had produced an annual development plan. This was being updated and the manager expected to complete this in the next month. The owners ensured that there are safe working practices within the home and complied with the relevant legislation. Policies and procedures were in place to
Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 25 ensure a safe working environment. All staff had received training in the various mandatory courses including health and safety, first aid, food hygiene and manual handling. Window restrictors had been fitted to all windows above the ground floor. Portable appliances were tested and the stair lift was regularly serviced. There were environmental risk assessments and these were regularly reviewed. The annual service of the boiler was slightly overdue. The manager was trying to obtain a date for service from the engineer. The environmental health officer (EHO) visited to conduct a health and safety inspection in September 2006 and there were no outstanding issues. The EHO conducted an inspection of the kitchen in June 2006 and made some requirements, some of which had been addressed. They visited again in January 2007 and agreed with the owner that the other requirements could be completed when the kitchen was replaced. Some kitchen cabinets had already been replaced and the owner planned to replace the others and replace the flooring. There was a fire risk assessment. At the last inspection some deficiencies were noted in relation to fire prevention and a requirement was made. Most of these had been addressed and all the required tests had taken place at appropriate intervals and been recorded in the fire log book. However, the record of the last two fire drills showed the quarter of the year when they took place but not the date. Fifteen out of twenty four staff had already received fire instruction in the first quarter of 2007 but seven staff had no record of fire instruction in the last quarter of 2006. All staff should receive fire instruction once a quarter and a record should be kept. Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 28 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 OP29 Regulation 12, and Misc amendment regs Requirement Before a new member of staff starts work, two written references must be received, a check must be made of the Protection of Vulnerable Adults List and a Criminal Records Bureau check must be applied for. The member of staff must be supervised by a designated member of staff until the CRB check is received. Timescale for action 31/01/07 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. Refer to Standard OP7 Good Practice Recommendations It would be good practice for each person to sign their care plan to show that they have been involved in developing it and are in agreement with it. When a person is not able to sign it would be good practice for a relative to sign on their behalf. All staff should receive fire instruction once a quarter and a record should be kept. When fire drills take place the date should be recorded. 2. OP38 Marlborough Lodge DS0000028337.V323175.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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
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