Inspection on 08/08/07 for Marlfield House

This inspection was carried out on 8th August 2007.

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.

Other inspections for this house

Marlfield House 06/06/06

Marlfield House 30/01/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Marlfield House Gilbert White Way Wooteys Alton Hampshire GU34 2LF Lead Inspector Ian Craig Unannounced Inspection 8th August 2007 10:10 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 Marlfield House DS0000063857.V342806.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. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlfield House Address Gilbert White Way Wooteys Alton Hampshire GU34 2LF 01420 83973 01420 542362 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) Hampshire County Council Mrs Anne Jacqueline Lewin Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40) of places Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Marlfield House is owned and run by Hampshire County Council Social Services Department and has provision for 40 residents to receive personal and nursing care. It caters for those aged over 65 years including those who may have dementia. The home opened in July 2005. The building is situated in landscape grounds with a central paved courtyard, water feature and sensory gardens. Accommodation is over two floors; a lift and stairs serve both floors. All bedrooms are en suite and there are a number of lounges and dining areas. The weekly fees for the home are £446.00. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of a tour of the building, examination of records including residents’ care plans and assessments of need. Two staff were interviewed and discussions took place with the registered manager. Staff were observed interacting with the residents for both activities and dealing with care needs. Two residents were interviewed. Questionnaires were sent by the Commission to a sample of residents, relatives and professionals involved with the home. Seventeen were returned and information contained in these questionnaires has been used for the purposes of this report. The inspection lasted approximately 4.5 hours. What the service does well: Residents’ needs are assessed before they are admitted to the home and each person has a care plan setting out how care is to be provided as well as details of each person’s leisure needs. The home has an activities coordinator who was observed engaging residents in exercise games which the residents enjoyed. Nutritious and varied meals are provided and there is a choice at each mealtime. The home is purpose built and provides an en suite toilet in every bedroom. The facilities are of a very good standard with a variety of lounges, bathroom facilities and adaptations for those with mobility needs. Adequate numbers of staff are provided and staff have access to various training courses. Meetings are held for residents and their relatives and minutes of these meetings show that the home’s management act on the suggestions of those attending the meetings. Feedback from residents, relatives and professionals connected to the home contained many positive remarks including the following: • “Health care needs appear to be very well met by the nursing staff.” • “All of the staff are very helpful.” Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 6 • • • “I am always made to feel very welcome when I visit. I am very happy with the care my relative receives.” “I have found the manager’s skills and experience and her general attitude to be helpful and totally professional.” “The staff appear to treat residents with kindness and respect and form good relationships where good humour is often apparent.” What has improved since the last inspection? What they could do better: Further action needs to be taken to ensure that residents or their relatives are involved in the assessment and care plan process. Regular staff supervision needs to be introduced and maintained. The home needs to maintain records to show that staff have undergone the required checks such as obtaining written references, criminal record bureau (CRB) and protection of vulnerable adults (POVA) checks. The home needs to devise policies and procedures for dealing with acute mental health needs. Staff need to receive guidance on these procedures. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 7 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. Marlfield House DS0000063857.V342806.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 Marlfield House DS0000063857.V342806.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): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive information about the home before they move- in to help them decide if the home is suitable. The home carries out an assessment of each person referred for possible admission to ensure that only those whose needs can be met by the home are accommodated. EVIDENCE: Professionals involved in the care of the residents, such as community psychiatric nurses and social workers, confirmed that the home carries out an assessment of the needs of any person referred for possible admission to the home. This is also supported by the home’s records, which show a Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 10 comprehensive assessment of need is carried out by the home before it is agreed that the person’s needs can be met. In addition to this, the home obtains copies of assessments and reports from referring social and health services such as hospitals and care managers. Residents and residents’ relatives confirmed that they received information about the home before moving in, although one person stated that he/she did not. One resident stated that his next of kin came to have a look at the home on his behalf to see if it suited his needs. Each resident’s records contain a copy of a contract outlining the conditions of living at the home. Residents confirmed that they are supplied with a contract. Marlfield House DS0000063857.V342806.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has a comprehensive care plan for personal care and nursing care. Residents’ health and personal care needs are met. The home promotes residents’ dignity and privacy. EVIDENCE: Assessments and care plans were examined for 4 residents. These were found to be very detailed and included assessments of need with a corresponding plan of care for the following: • Communication Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 12 • • • • • • • • • • • • • • • • • • • Relationships/social contact Interests and activities Spiritual/religious/cultural practices Health Physical activities/moving and handling/aids for mobility Memory General well being Routines and preferences Nutrition Medication Washing Dressing Shaving Hair care Bath/shower Oral hygiene Optical/audio care Foot care Support/buying/choosing clothes Each person also has a Daily Living Plan and a Nursing Intervention Care plan with greater detail than the above care plan. Assessments, plans and monitoring forms are used for specific needs more requiring specialist care such diabetes blood sugar, pressure sore risk, nutrition, risk of falls and weight. A separate care plan is recorded for night time. A review form is completed showing that changing needs are reassessed. Mental health needs are assessed by the home and recorded with guidelines for staff to follow in dealing with confusion and disorientation. Health and social services professionals comment that the home is able to meet the physical health needs of the residents, but that a greater expertise in dealing with the dementia needs of the residents would be beneficial to residents. Staff have received training in working with older persons who have dementia. During the visit the staff were observed dealing with the mental health needs of one resident in a tactful and diplomatic way that ensured the safety of the person and the other residents. From discussion with the staff and manager, it was concluded that whilst staff have knowledge of the roles of community health and social services for assisting those with mental health needs, that clear guidelines and procedures should be developed for tackling emergency and acute symptoms. Staff should also have knowledge of this. The manager, and her service manager have already initiated this, as a result of a review of another incident. The home’s medication procedures were examined. These were found to be satisfactory with records maintained by staff when medication is administered. Procedures for storing, handling, recording and administering controlled medication are also satisfactory. The Commission has received notification of Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 13 one incident where there was an error in the home’s medication procedures, which was followed up the home’s management. Each staff member involved with medication receives training. This was confirmed from training records and from staff. Residents described the staff as kind and helpful. One relative stated that the staff are friendly. The two residents interviewed stated that their care needs are met. Each resident has his or her own room, which ensures privacy. One person has a key to his/her bedroom. The manager stated that the remaining residents are offered a key. It was advised that when a key is offered to a resident for his or her room that a record is made of the response as well as any decision when a resident is assessed as not capable of safely handling a key. Marlfield House DS0000063857.V342806.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with activities and stimulation although opportunities for trips out from the home are limited. A varied and nutritious diet is provided and residents have a choice of food. EVIDENCE: Since the last inspection an activities coordinator has started work at the home arranging and providing activities from Monday to Friday. Feedback from residents and relatives refers to the recent improvement in the provision of Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 15 activities, although one professional states that the home’s staff do not have sufficient skills to provide stimulation for those with dementia. A notice gives details of the daily activities schedule, which includes a morning and afternoon activity each day Monday to Friday, such as, crosswords, games, crafts, music sessions and entertainment from visiting musicians. A group of residents were observed enjoying a ball game exercise. One resident stated how much he likes the activities, saying, “It’s great here. There’s lots to do.” Another resident stated how he was looking forward to having an afternoon cream tea in the garden. Individual resident’s needs regarding social and leisure interests are assessed and recorded. The provision of activities could be improved by extending planned activities into the weekend and by offering residents opportunities to go out. One resident stated that he has not been able to go out. This was discussed with the manager. The home does not have access to transport for taking residents out. Progress on facilitating outings for residents will be checked again at the next inspection. Several residents were observed reading books and one person stated that it is possible to have a newspaper delivered. The home has a stock of books. One person stated that books have only been recently provided after the subject was raised. At present the mobile library does not visit the home but the manager stated that this is being arranged. The home has a menu plan showing a varied and nutritious diet with a choice at each meal. The menu plan is displayed in the dining areas. Residents described the food as good and confirmed that there is a choice of food at each mealtime. A visiting professional commented that the home could be improved by asking each person what their likes and dislikes are regarding food. The manager responded to this by stating that the menu plan was devised with the residents and that there is a choice at each meal to cater for each person’s different tastes. Marlfield House DS0000063857.V342806.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home acts on any complaints made. Residents are protected from abuse, although the home needs to ensure that emergency procedures are in place to deal with challenging behaviour. EVIDENCE: The home’s complaints procedure is available in the entrance hall and is contained in the information given to service users when they move in. Residents confirmed that they have a copy of the procedure and know what to do if they have a complaint, although one person stated that he/she does not know what to do. The home has a folder with a record of any complaints made. Not all staff have completed training in adult protection procedures although each staff member is booked to attend a course in the subject. The home has a folder recording details of any adult protection referral showing that residents are protected when appropriate referrals being made. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 17 Staff were observed dealing with an incident of challenging behaviour, which was dealt with calmly and competently. Residents’ care plans include details of how staff should handle aggressive behaviour. As previously stated, the home delayed making a referral for a medical assessment of a resident, although other measures were taken to protect the person by increasing the staffing quota and introducing a robust monitoring regime. The manager and her line manager have discussed this, with agreeing that a more proactive intervention should have been taken. This now needs to be formalised into guidance and policy for staff to follow who should be made aware of the procedures. Marlfield House DS0000063857.V342806.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, 21, 22, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home that is purpose built to a high standard, with adaptations for those who have mobility needs. EVIDENCE: Parking is available at the front of the home for visitors. The grounds are well maintained with various shrubs and flowers as well as areas where residents can sit. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 19 The entrance door to the home opens by button and each doorway is wide enough for a wheelchair to negotiate. The home has a variety of lounges each with a linked dining space and a small kitchen. These are well decorated and furniture is in good condition. Each of the lounges has a television with cable television channels including Sky service, which is included in the contract price. Each bedroom is single and has an en suite toilet. Some of the rooms have a track hoist for those with mobility needs. Television aerial points are provided in each bedroom and residents can have their own telephone line installed. Attractive nameplates with a signature picture have been placed outside each bedroom door, so that the resident knows which bedroom is his or hers. Corridors are painted in a variety of pastel colours deliberately designed for a calming effect and to help residents orientate themselves. The home has a passenger lift. Underfloor heating is provided a thermostat control in each bedroom. Residents are protected from possible hot water scalds by hot water mixers on baths and showers and from possible falls from windows by restrictors. There are a variety of bathroom facilities including a walk in shower and specialist baths with lifting devices. Baths can also be raised and lowered by staff so that residents can be accessed without staff having to bend over. All areas of the home are clean and hygienic. There was an absence of any unpleasant odours such as those caused by incontinence. Staff receive training in infection control. Laundry is placed in different bins according to the type of wash required. The home has sluice facilities for dealing with soiled items. One person stated that residents’ laundry has become lost due to a lack of labelling. This has been addressed and the manager has ordered name tags, which will be sown into each resident’s item of clothing. The home has a call point system, which allows residents to attach it to their wrist like a watch so that it can be worn around the home. The call points can only be deactivated by staff at the source of the call. One person stated that the call point is not always responded to, but this was the only reference to this happening. Residents described how they like the environment. Marlfield House DS0000063857.V342806.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. Staff are provided in sufficient numbers to meet the needs of the residents, which can be increased at short notice to deal with changing needs, and for the protection of the residents. The home has been relying on agency staff, which may affect continuity of care and the availability of a suitably trained work force. Improvements have been made so that staff have access to relevant training courses, although staff do not receive adequate supervision. The home does not maintain records to show that new staff have undergone the required checks, which protect residents. EVIDENCE: The home aims to deploy a ratio of 1 staff member for 4 residents during the hours of 7.30am to 3.30pm and 1 staff member to 5 residents from 3.30pm to Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 21 10.00pm. The staff rota showed that this is being achieved. There have been a number of staff vacancies in the recent past. At the time of the inspection the home had 4.5 staff vacancies but had recently appointed a further 2.5 staff. These staff will start work in the near future. The home uses agency staff to cover any shortfalls. For the week of the inspection the home was using 202.5 agency staff hours from a total of 1,295 staff hours. Feedback from residents, residents’ relatives, and professionals, generally gave the view that the home has enough staff and that the staff are kind and polite. Two people felt that there are not enough staff and one resident described a high turnover of staff, which he/she found unsettling. The home’s manager described how she has tried to provide consistency of agency staff by using the same agency and the same staff as far as is possible. Further recruitment of staff is planned which will address this. The home’s staff described how the numbers of permanently staff has increased in the last year. The manager explained that staffing levels can be increased at short notice so that residents needs can be met. Care records showed that this had occurred recently where needs had increased and a resident required 1 staff member at all times. Night time staffing consists of 1 staff member to 8 residents. At least 2 registered nurses are on duty at any given time, with three on duty for the 7.30am to 3.30pm shift. Staff training consists of a variety of courses such as health and safety, moving and handling, falls risk assessment, medication, infection control, dementia, use of the home’s call system, IT, syringe driver, care planning, reporting and recording, fist aid, adult protection, gastronomy care, wound care, life support and practical care. Since the last inspection 3 care staff have commenced NVQ level 2 training and a further 8 staff are due to start the course in September 2007 and January 2008. Staff confirmed that there are a variety of training courses available and that individual performance is formally monitored. The home has introduced a performance appraisal of individual staff entitled, Individual Performance Plan. Regular staff meetings are held so that staff have opportunities to discuss their work with other staff and with the home’s management team. There is insufficient evidence of staff receiving formal supervision. For 3 staff chosen at random, supervision records were infrequent. The manager acknowledged that this is an area of management that needs to be developed and she has highlighted this as a target for achievement in the near future. Recruitment procedures were examined for 3 staff chosen at random. The service is required to have records to show that recruitment checks have been carried out. These were only available for 1 of the 3 staff whose records were Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 22 looked at. This was discussed with the manager who has taken steps to obtain these records from the County Council’s personnel department. The inspector highlighted the current Commission guidance on the internet regarding staff records being held centrally for organisations and the records that must be held at each service. Marlfield House DS0000063857.V342806.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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the skills to run the home. The views of service users, and their relatives, are sought and incorporated into the future plans, although this needs to be extended. Measures are taken to protect residents’ finances and to ensure their safety. EVIDENCE: Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 24 The manager has completed a management induction course. At present she is studying the NVQ 4 in care and the Registered Manager’s Award. Professionals involved in the home gave positive feedback about the manager’s skills and competence. The home’s staff also described the manager as approachable, supportive and a good team leader. A staff member stated, “We have seen the home grow and develop.” The home is still in the process of developing its quality assurance systems. Residents have been canvassed for their views about suitable activities that they would like to attend. The results of these have been used to organise the activities programme. A survey questionnaire covering a wider range of the home’s provision has not yet been given to residents, relatives, staff or professionals. The manager explained that this is a target for the near future. A copy of the home’s service plan for the year 2006/2007 is available in the hall. The manager carries out audits of the home’s medication procedures and the care of the residents. A member of the County Council’s management team completes monthly audits and a report. The home has a safe for holding any residents’ money or valuables. Records are maintained of any amounts deposited or withdrawn plus a corresponding balance. The home does not hold any resident’s money in a bank account. The home’s fire logbook shows that fire safety equipment is serviced and tested according to fire safety regulations. Records show that staff receive instruction in fire safety and that fire drills take place. The home’s equipment and appliances are serviced by suitably qualified persons. Staff receive training in first aid, food hygiene, moving and handling and infection control. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X 4 4 X 4 4 3 STAFFING Standard No Score 27 2 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 2 X 3 Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 19 Schedules 2 and 4 Requirement The home must maintain records to show that the required checks in the form of 2 written references, a criminal record bureau and protection of vulnerable adults checks, have been carried out on each staff member. Records must be available to show that the home has obtained an employment history for each person employed. Staff must receive regular formal supervision. Timescale for action 30/09/07 2 OP36 18 01/11/07 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 OP18 Good Practice Recommendations The home should devise written policies and procedures DS0000063857.V342806.R01.S.doc Version 5.2 Page 27 Marlfield House for dealing with emergency and acute mental health needs of residents. Staff should receive guidance in these procedures. Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Marlfield House DS0000063857.V342806.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!