Inspection on 15/04/08 for Marley Court Nursing & Residential Home

This inspection was carried out on 15th April 2008.

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

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

Other inspections for this house

Marley Court Nursing &... 13/10/09

Marley Court Nursing &... 06/11/08

Marley Court Nursing &... 16/07/07

Marley Court Nursing &... 27/02/06

Marley Court Nursing &... 12/10/05

Marley Court Nursing &... 17/01/05

Marley Court Nursing &... 17/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marley Court Nursing & Residential Home Bolton Road Heath Charnock Chorley Lancashire PR7 4AZ Lead Inspector Mrs Susan Hargreaves Unannounced Inspection 15th April 2008 10:25 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 Marley Court Nursing & Residential Home DS0000025550.V359152.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. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marley Court Nursing & Residential Home Address Bolton Road Heath Charnock Chorley Lancashire PR7 4AZ 01257 226700 01257 234407 marleycourtnh@aol.com 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) Marley Court Nursing Home Limited Maxine Henry Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 49 service users in the category of OP (Old age, not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines that may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 16th July 2007 Date of last inspection Brief Description of the Service: Marley Court is a purpose built home, which is registered to provide both personal and nursing care for older people. The accommodation at Marley Court is offered on two floors, the first floor being accessed by stairs or passenger lift. There are a range of single rooms some with en suite facilities and double or companion rooms, some of which also have en suite facilities. There are two lounge/dining rooms, one on each floor and a range of toilet and bathing facilities throughout, there is also a fully equipped laundry. There is a large patio area at the front, furnished with hardwood garden furniture and set around a central fountain. This area, along with the side gardens is fully accessible to residents, regardless of mobility. As Marley Court is situated on the main A6 road from Chorley to Adlington it is well provided by public transport. The current fees charged at Marley Court are £424 to £533 per week. Additional charges are payable for hairdressing, newspapers, chiropody and toiletries. A statement of purpose and service user guide was available to prospective residents and their relatives on request. Marley Court Nursing & Residential Home DS0000025550.V359152.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 1 star. This means the people who use this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Marley on the 15 April 2008. One additional visit has been made since the last inspection. This was a random inspection carried out by a pharmacist inspector on 27 September 2007 in response to concerns about the administration of controlled drugs prescribed to be given ‘when required’. Six completed surveys were received from residents, five from the relatives of residents and five from members of staff. The manager was asked to complete an annual quality assurance assessment and return this to the commission several weeks before the visit to the home. This document provides important information about how the home is being managed and is an essential part of the inspection process and was not returned until 6 May 2008. At the time of this inspection 42 residents were living at the home. A tour of the premises took place and staff files and care records were inspected. Members of staff on duty, residents and visitors were spoken to. Discussions also took place with the deputy manager regarding issues raised during the inspection. The manager was on holiday at the time of the inspection and further discussion with her took place by telephone on 22 April 2008. What the service does well: All the residents spoken with praised the staff for the care they received. One resident said, “The staff are friendly and obliging.” Another resident said, “They look after me, the staff are very good.” Visitors were welcomed into the home at anytime. The relative of one resident said he visited everyday and stayed for tea. Residents said they could get up and go to bed when they wanted. One resident said, “I get up at 8am and go to bed at 9.30pm.” One resident said about the home, “I can’t find anything wrong with it, it’s home from home.” All the residents asked said the meals were good. One resident said, “The meals are quite good, like you would get at home.” Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 6 Training for all members of staff was encouraged. More than 50 of the care workers had an NVQ qualification in care at level 2 or 3. What has improved since the last inspection? What they could do better: It is of serious concern that requirements made about care planning following the last inspection have not been met. Urgent action must be taken to ensure all care plans accurately identify and address all the care needs of each resident. Care plans must be up dated when the needs of the resident change. Wound care records must also be kept up to date and give detailed information about the care and condition of the wound. When a clinical decision has been made that a wound swab is necessary this must be obtained on the day stated in the care records to enable the resident to promptly receive any required medical treatment. Where possible the resident or their relatives should be involved in care planning. This ensures members of staff know exactly what they have to do in order to provide person centred care. It is important that a risk assessment for the development of pressure sores completed for each resident. This ensures prompt action can be taken to help prevent pressure sores if necessary. To promote the health and wellbeing of all residents it essential that medication is managed correctly. A record of all medication received into the home must be kept. If medication is omitted the reason for doing so must be given. The amount of medication left over from the previous month should be written on the new medication administration record. This ensures medication can be accurately audited in order to prevent misuse. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 7 Written instructions should be in place for staff to follow to ensure medication prescribed ‘when required’ is given correctly. To ensure medication has been ordered correctly registered nurses should check the signed prescriptions before the pharmacist dispenses them. It is essential that the wishes and dignity of all residents be respected. Arrangements must be made to ensure that a sufficient number of staff is available at meal times to enable personal care to be given to individual residents when required. To ensure the recreational needs of residents are met these must be clearly recorded in their individual care plans. Residents should also be consulted about the leisure activities provided and changed if necessary to ensure individual needs are met. Several residents and their relatives expressed their concerns about staffing levels. These should be reviewed to ensure a sufficient number of staff are always on duty to fully meet the needs of the residents. This includes answering call bells promptly and not keeping residents waiting for as long as fifteen minutes. It is of serious concern that the manager failed to return the annual quality assurance assessment when requested. The manager must complete and return this and any other documents requested by the Commission on time. Please contact the provider for advice of actions taken in response to this inspection. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 8 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. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 9 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 Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 10 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough admissions procedure ensured sufficient information was obtained in order to identify the needs of each resident. EVIDENCE: A copy of the statement of purpose and service user guide is available to prospective residents and their relatives on request. These provide information about the care and facilities provided at the home. The manager or a senior member of staff visited and assessed prospective residents in hospital or their own home prior to admission. The care records of two residents recently admitted to the home included a pre-admission assessment. These assessments provided important information for the care plans to be developed. Standard 6 is not applicable to this service. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 11 Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Deficiencies in care planning and the management of medications means residents do not always receive person centred care. EVIDENCE: The individual care plans of four residents were inspected. These plans did not identify and address all the care needs of each resident. This meant that members of staff were not fully aware of how to provide person centred care for each resident. One resident who suffered from diabetes did not have a detailed care plan in place explaining how this condition was to be managed. Not providing clear directions for staff to follow can seriously affect the health and welfare of the resident. A care plan about the behavioural problems for one resident did not clearly explain what triggered these problems or advise staff how to prevent and deal with such behaviour. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 13 One resident had a skin problem but a care plan giving clear directions for staff to follow about the care needed was not in place. Failure to include clear instructions for staff to follow could seriously affect the health and welfare of the resident. A care plan written in 2006 for another resident stated she had generalised rashes. The nurse on duty said this was no longer a problem. Although the care plan had been reviewed monthly it had not been up dated when the needs of this resident changed. The wound care records for one resident were confusing and had not been updated when the condition of the wound changed. There was a lack of detailed information about the size and condition of the wounds. The records stated on 13 April that a swab was to be taken on 15 April but there was no evidence to suggest that this had been done. Not taking a swab could have delayed treatment and affect the health and wellbeing of the resident. Although risk assessments for falls and nutrition were in place a risk assessment for the development of pressure sores for one resident had not been carried out. This meant that potential risks to health were not identified before a problem occurred. To ensure the safe use of bed rails a risk assessment is carried out for individual residents who need them. All four care plans included a consent form which relatives were asked to sign giving consent for the use of bed rails as restraint. Bed rails should only be used to prevent a resident from falling out of bed and not as a form of restraint. This document does not comply with the Mental Capacity Act because there was no evidence an assessment of the resident’s mental capacity had been carried out when it was considered necessary to use bed rails. Care plans and risk assessments were reviewed monthly. However, there was no evidence to suggest except for the consent form about bed rails that the resident or their relatives had been involved in care planning. This means that residents and their relatives may not have been consulted and agreed with the way in which care is being given. There were records of the involvement of GP’s in the care of the residents. In order to ensure members of staff have up to date information about the care and condition of each resident a written report is completed during each shift. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 14 Medication was stored safely and securely in locked trolleys and cupboards inside a locked utility room. Records for the management of medication were in place. However, a record of the receipt of medication for a recently admitted resident had not been made. Controlled drugs were stored securely and a stock check was satisfactory. Registered nurses do not see the signed prescriptions before the pharmacist dispenses them. This is important in order to ensure medication has been ordered correctly. Medication could not be accurately audited for one resident because the amount of medication left over from the previous month had not been written on the medication administration record. It was recorded on the administration record for one resident that medication and the application of ointment had been omitted. However, the reason why they had been omitted was not given. Omitting medication without giving a valid reason could put the health and welfare of residents at risk. Several residents were prescribed medication to be taken ‘when required’ without clear instructions for staff to follow to ensure they were given correctly. Clear instructions help ensure residents are given their medication when it is needed. Members of staff were observed attending to residents in polite and friendly manner. Personal care was carried out in the privacy of the resident’s own room or the bathroom. One resident said, “The staff are very nice.” A visitor said, “The staff are lovely.” However, another visitor said their relative had recently been left sitting on the commode for about an hour because it was teatime. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s decisions were respected but the range of leisure activities provided did not meet the needs of some residents. Meals were wholesome and appetising and residents enjoyed them. EVIDENCE: Although care plans about social interests were seen in the files of three residents one of these did not clearly state what the resident’s interests and hobbies were. This means some residents may not be enabled to pursue their preferred leisure activities. An activities co-ordinator was responsible for organising a range of leisure activities. These included, manicures, listening to music, watching films, bingo, dominoes and a variety of games. On the afternoon of the inspection three ladies were observed played quoits with the activities co-ordinator in the ground floor lounge. One member of staff said two residents went to the ‘library’ bookshelves in the home to choose books to read and another resident had been given a duster because she enjoyed dusting. However, one resident said, “We’re short of activities and something to do.” One resident commented on the survey that residents were not always aware of what was going on. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 16 The relative of a resident wrote on the survey, ‘socialising isn’t encouraged and there is usually not enough for them to do’. The relative of another resident wrote, ‘there seems little consistent effort to provide regular stimulus for the residents’. Discussion with residents and staff confirmed the daily routine was flexible and residents could choose when to get up and go to bed. Regular contact with for residents with family and friends was considered to be an important part of their life. Visitors were welcomed into the home at anytime and offered refreshments. One visitor said he regularly stayed for tea. All the residents asked said the meals were good and they were always given a choice. One resident said, “I’ve always had enough to eat.” Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints were taken seriously and investigated. Staff had the training necessary to ensure residents were protected from abuse. EVIDENCE: A copy of the complaints procedure was displayed in the home and included in the service user guide. One resident said she knew how to complain and would do so if necessary. Records of any complaints were kept including information about the investigation and action taken. Since the last inspection the manager has investigated two complaints one made directly to her and one made to the Commission. Policies and procedures about the safeguarding of vulnerable adults were in place. This issue was discussed with two members of staff they said they would report any concerns immediately and knew the procedure. Training records confirmed that members of staff had received training in safeguarding vulnerable adults. Marley Court Nursing & Residential Home DS0000025550.V359152.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were well maintained and provided a comfortable and ‘homely’ environment for the residents. EVIDENCE: At the time of the inspection the home was clean, tidy and well maintained. One resident said, “It’s home from home.” One resident wrote on the survey that domestic staff were courteous, friendly and willing to help if they can. Residents were encouraged to bring personal items for their bedrooms to make them more homely. These included, ornaments, photographs etc. The relative of a resident commented on the survey that the rooms and facilities were very good. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 19 The grounds and gardens were well kept and accessible to residents if they wished to sit outside when the weather permitted. All the laundry was done at the home. A suitably equipped laundry room ensured clothes were washed promptly and returned to the residents. One resident said, “Two nice ladies worked in the laundry.” Plastic gloves and aprons were available for staff to protect them and the residents from infection. Marley Court Nursing & Residential Home DS0000025550.V359152.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Members of staff were encouraged to acquire the skills and knowledge needed to provide effective care for the residents. Recruitment procedures were thorough. Staffing levels may not be sufficient to provide person centred care for all residents. EVIDENCE: The duty rota provided information about the grades and numbers of staff on duty on each shift. Two members of staff commented on their surveys that there was not enough staff. One resident explained that staff might answer their buzzer straight away or it could take fifteen minutes if they were busy. One resident wrote on the survey ‘the response time to pressing the call button is frequently poor.’ Another resident expressed their concern about the lack of care staff on duty particularly at the weekends. The relative of a resident wrote on the survey, ‘Sometimes an inordinate time is taken to respond to a call. This is due to understaffing.’ The relative of another resident wrote, ‘because the home is always short staffed this affects care.’ During the afternoon of the inspection a visiting relative said there were two care workers on duty and he thought there needed to be three. On the day of the inspection only four residents were observed using the ground floor lounge, and none of the residents were seen to use the first floor lounge. Most of the residents were cared for in their own bedrooms. This Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 21 made it difficult to observe how often members of staff attended to individual residents. The records of four members of staff appointed since the last inspection were examined. These files indicated that all the required pre-employment checks to ensure protection of the residents had been completed prior to appointment. However, one member of staff had provided a copy of her Curriculum Vitae and had not completed an application form. The deputy manager was advised that all applicants should fill in a job application form in order to ensure that all the necessary information is obtained. Discussion with members of staff and inspection of training records confirmed that training was encouraged. This included induction training for new employees, moving and handling, health and safety, fire safety, basic food hygiene, first aid and safeguarding vulnerable adults. In addition to this ten care workers had an NVQ level 2 in care, five had level 3 and two were working towards level 3. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 22 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): 31,33,35,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager failed to return the annual quality assurance assessment to the Commission by the date requested. The views of residents are considered when decisions about the care and facilities provided at the home are made. EVIDENCE: The registered manager is an experienced nurse and has an NVQ level 4 in management. Members of staff said she treated everyone the same, was easy to talk to and professional. They also said that teamwork had improved and they had been given additional responsibilities as key workers, which made them feel important. Although an annual quality assurance assessment form was sent to the home for the manager to complete several weeks before this inspection this was not Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 23 returned by the date requested. The purpose of this document is to provide the inspector with information about how the home is being managed and any action the manager is making or intends to make in order to improve the quality of life for residents living at the home. The manager identified recruiting more staff to avoid the use of agency workers as an area for improvement. The home has achieved the nationally accredited Investors in People award. Meetings with residents and their relatives took place regularly to enable them to express their views and discuss the care facilities provided at the home. Satisfaction questionnaires were also given out to residents and their relatives annually in May and evaluated to assist in decisions about improvements to the care provided. A newsletter had been circulated to residents and their relatives in February. This provided information about the new activities co-ordinator, staff training and resident’s birthdays. A number of residents had money kept at the home to pay for hairdressing, chiropody and other personal needs. Records of transactions involving resident’s money were seen to be to date and accurate. The responsible individual visited the home regularly and discussed the care provided with residents and staff to ensure the home was effectively managed. Reports of these visits were seen for the first three months of this year. Fire alarms were tested weekly and although the emergency lighting had been serviced in December 2007 records of regular testing were not available. Fire drills were held every few months and staff attendance records were kept to ensure all members of staff received this training. Records of the routine servicing of equipment were seen. These included gas and electrical installation certificates and evidence that the testing of small electrical appliances had taken place in September 2007. These checks help to ensure the home is a safe place for the resident to live. Records maintained in the kitchen included fridge, freezer and food temperatures and a cleaning schedule. This ensures food is stored correctly and handled safely. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 3 3 Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement Timescale for action 30/05/08 2 OP7 15(2)(a)( b)(c)(d) 3 OP8 12(1)(a) (b) 4 OP8 17(1)(a)S chedule 3(n) To ensure the care needs of all residents are met. Care plans must accurately identify and address all the care needs of each resident. This includes behavioural problems and healthcare. Timescale 31/08/07 not met. To ensure staff have the 30/05/08 information necessary in order to meet the needs of all residents care plans must be up dated when the needs of the resident change. Residents or their relatives must be involved in care planning. Timescale of 27/10/06 and 31/08/07 and 05/11/07 not met. To ensure appropriate action is 30/05/08 taken to prevent residents from developing pressure sores a risk assessment must be completed for each resident. To ensure residents receive 30/05/08 effective wound care detailed records must be kept about the condition of the wound at each dressing change. Timescale of 6/10/06 and DS0000025550.V359152.R01.S.doc Version 5.2 Marley Court Nursing & Residential Home Page 26 5 OP8 13(1)(b) 6 OP9 13(2) 7 OP10 12(3) 8 OP31 24 31/08/07 not met. To enable residents to receive any necessary treatment a wound swab must be obtained on the day stated in the resident’s care records. To ensure medication is managed correctly a record of the receipt of all medication received into the home must be kept. If medication is omitted a reason for this must be recorded. Arrangements must be made to ensure that a sufficient number of staff is available at meal times to enable personal care to be given to individual residents when required. To assist in the assessment of the care home as part of the inspection process the manager must complete and return the annual quality assurance assessment by the date specified to the Commission. 18/04/08 30/05/08 16/05/08 06/05/08 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 OP7 2 OP9 3 OP9 Refer to Standard Good Practice Recommendations The form relatives of residents have signed giving consent to the use of bed rails should not be revised in order to comply with the Mental Capacity Act. Medicines prescribed as when required or, as a variable dose should have clear written instructions for staff to follow to ensure they are given correctly. All prescriptions should be checked before the pharmacist dispenses medication. This ensures medication has been ordered correctly. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 27 4 OP9 5 OP12 6 OP27 7 OP29 8 OP38 The amount of medication remaining from the previous month’s supply should be recorded on the new medication administration record. This ensures medication can be accurately audited in order to prevent misuse. Residents should be consulted about leisure activities to ensure the programme meets the recreational needs of as many residents as possible. Care plans should clearly state the social interests and hobbies of each resident. Staffing levels should be reviewed to ensure they are appropriate to fully meet the needs of the residents including answering call bells promptly. To ensure detailed information about all applicants to work at the home is obtained it is strongly recommended that they complete an application form. Emergency lighting should be checked regularly to ensure it is working properly throughout the home. A record of these checks should be kept. Marley Court Nursing & Residential Home DS0000025550.V359152.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Marley Court Nursing & Residential Home DS0000025550.V359152.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. 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