Inspection on 15/12/05 for Marling Court

This inspection was carried out on 15th December 2005.

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

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

Other inspections for this house

Marling Court 14/08/07

Marling Court 02/06/06

Marling Court 09/06/05

Marling Court 21/10/04

Marling Court 20/05/04

Marling Court 01/07/03

Similar services:

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Henry Nihill House

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

CARE HOMES FOR OLDER PEOPLE Marling Court Bramble Lane Off The Avenue Hampton Middlesex TW12 3XB Lead Inspector Sandy Patrick Unannounced Inspection 15th December 2005 10:00 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 Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 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. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marling Court Address Bramble Lane Off The Avenue Hampton Middlesex TW12 3XB 020 8783 0157 02087830078 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) Richmond upon Thames Churches Housing Trust Care Home 37 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (20), Physical disability over 65 of places years of age (20) Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To admit one named female service user aged 63 years. The Registered Person must ensure that all staff are appropriately trained in dementia care. 9th June 2005 Date of last inspection Brief Description of the Service: Marling Court is a purpose built residential care home in Hampton providing personal care and accommodation for up to thirty-seven people. Up to twentyfive of whom may have dementia. The number of places registered for service users with dementia was increased from seventeen in November 2004, when the home applied for a variation to the categories of registration. A condition of this variation was that all staff must be appropriately trained in dementia care. Marling Court is situated close to local facilities and amenities and is set within a residential area. The home’s internal décor is pleasing with a large homely lounge. There are four interconnecting units, each with its own kitchenette, sitting and dining area. The lobby area is welcoming and off this are the Manager’s office, the duty office, the kitchen and laundry. The home has attractive gardens accessible to service users. CCTV cameras monitor the entrance and nearby designated parking spaces. The home is owned and managed by Richmond upon Thames Churches Housing Trust. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 15th December 2005, and was unannounced. The Inspector met with the Manager, other staff on duty, service users and visitors. The Inspector was made welcome by all. Service users were preparing for Christmas and festive events were taking place throughout December. The atmosphere at the home was lively and positive. Staff treated service users with respect and kindness. The Inspector spent time on each unit at the home and met with many of the service users. Service users told the Inspector that they were happy living at the home and that they were well cared for. What the service does well: What has improved since the last inspection? The Manager told the Inspector that she feels assessments made on potential service users have improved and staff now know more about new service users and how to meet their needs. There have been improvements to care planning and related records. A great many activities had been arranged during December and over the Christmas period. Service users are encouraged and supported to participate in these. A new NVQ training provider has started work with staff at the home. The Manager reported that some staff have undertaken specialist training in dementia care. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 6 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. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 7 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 Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 There is a range of information available about the service to help people to decide whether they wish to live at the home. There is an appropriate procedure for assessing and reviewing the needs of service users. Service users are admitted on a trial stay so that they and the staff can decide whether the service can meet their needs. EVIDENCE: The Service User Guide and Statement of Purpose for the home include the required information and are available to service users. There have been no changes to these documents since the last inspection. Individual licence agreements are in place for all service users. These include terms and conditions of residency, a charter of rights and copies of the complaints and admissions procedures. Copies of contracts are given to service users and a copy is held by Richmond Churches Housing Trust. The Manager or senior staff meet with potential service users and conduct an assessment of needs. Assessments include information from the service user Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 9 and their representatives. Copies of assessments were seen by the Inspector. Potential service users are invited to visit the home before they make a decision about living there. Service users who spoke with the Inspector confirmed that they had done this. Service users move to the home for a six week trial stay. At the end of this time, they meet with the Manager and their own representatives to decide whether they wish to continue to live at the home and whether the home can meet their needs. Annual review meetings take place to make sure the service user’s needs continue to be met. The Inspector saw evidence of these review meetings within individual service user’s records. The Manager told the Inspector that she felt pre-admission assessments had improved over recent months and staff were given more information on individual needs than in the past. The Manager said that particular attention was being given to finding out more about social needs and personal histories. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Individual needs are recorded in a clear and accessible format. Service users and their representatives are involved in the development and review of their plans. Some additions to care plans should be made. Health care needs are appropriately recorded and met. The medication procedure is designed to safeguard service users. Practices around medication storage, recording and administration are generally good, although some developments are necessary to minimise risks to service users. EVIDENCE: Each service user has a care plan which is designed to record their individual needs. Service users have been involved in the development of these and have signed copies of their own plans as a record of their agreement. Care plans have been reviewed monthly and following changes in need. This has been recorded. The Inspector examined eight individual care plans and related records. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 11 Care plans give information on a range on different needs and information is clearly recorded. However, the information on different social needs, hobbies and interests is limited in some care plans. The Manager told the Inspector that improvements to the initial assessments had led to more information on social needs being recorded. Further work to identify and meet the individual social needs of the current service user group should take place. Copies of the care plans are held in the duty office and on units where service users live. The care plans on the units do not have photographs of service users nor do the medication administration records. Photographs may help new or unfamiliar staff to identify service users and it is important that these are available on the units for this reason. There is an appropriate medication procedure. Medication within three of the units was examined. One cabinet used for storing medication was not secure and could be opened without the key. The cabinet must be equipped with a more suitable lock. In one unit there was a box of painkillers labelled ‘stock’. The practice of holding ‘stock’ medication which has not been prescribed to an individual service user is unsafe and must cease. Where individual service user medication has been carried over from one month to the next, the amount carried forward had not been recorded and should be. Service users are registered with a number of local GPs, and are able to retain their family GP if they are local. There is evidence of input and support from other health care professionals. Details of consultation and interventions are recorded. Health care needs, including information from health care professionals, is recorded within service user plans. Personal care needs are recorded and monitored in service user plans. These include personal choices. These indicate that service users are able to rise, retire and take meals at the time of their choosing. Each service user is allocated a keyworker who offers specialist support, including support with purchasing personal shopping and toiletries. Service users confirmed that they were able to rise and retire when they wanted. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 The planned programme of activities offers some regular and widely enjoyed events. However, participation in many of the activities is low and further developmental work around activity provision is necessary, so that service users are able to choose from a wider range of activities designed to meet individual needs. EVIDENCE: The home does not employ an Activities Officer. There is a planned programme of activities designed to be held in each unit. Some weekly activities, such as music and movement, singing, entertainers and outings are designed for service users from the whole house. The general activities programme includes quizzes, craft work, reminiscence, fortnightly church services and weekly visits by a hairdresser. Service users and staff on the units reported that in general activities were organised on an ad hoc basis according to wishes and needs on the day. This flexibility is important and should continue. However, on some days limited activities are available to service users and the staff on the units report that they do not have sufficient time to meet these social needs. Staff report that many service users do not want to join in with planned activities. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 13 During December, there was a good range of organised activities. On the day of the inspection children from a local school came to sing carols and a staff and service user karaoke session was held in the main lounge. These activities were clearly enjoyed by service users and they spoke about other Christmas activities, such as card making, a pantomime and entertainers which they had enjoyed. A Christmas party and raffle had been held and a New Years Eve party was being planned. The home is commended for organising this extensive range of activities, which were advertised to service users in an attractive way. The Registered Person must look at how activity provision in general can be improved and participation in activities encouraged. This area was discussed with the Manager at this and at the last inspection and a requirement made. This requirement is not yet met and further work to improve this area of service must take place. It is important that someone oversees activity planning and provision. The success of activity provision should be monitored and the programme reviewed to reflect the wishes of service users. The needs of service users at the home are changing with the changes to the registration categories of the home. The staff at the home need training and support to understand the needs of people who have dementia. On the day of the inspection one service user was having a birthday. This service user told the Inspector that birthdays were always celebrated with cake and a buffet tea and that this was what they wanted. The Inspector saw one service user helping with the drying up in a unit. The service user told the Inspector that they were able to tidy their rooms and help with other household jobs if they wanted to. This is positive and service users should be supported to participate in this way if they wish and following a risk assessment, where necessary. The atmosphere throughout the home was relaxed and the Inspector observed service users and staff in all units chatting, sharing jokes and listening to music together. There is a varied menu offering choices at each mealtime. Service users make choices about their meals the day before. Staff in one unit were observed to support service users appropriately during mealtimes and offer them choices. The Chef visited the unit during the meal to ask service users about their enjoyment of the food. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 There is an appropriate complaints procedure, which is accessible to service users. All service users have a representative external to the home. Procedures designed to protect service users are in place. EVIDENCE: There is an appropriate complaints procedure that includes timescales and information on contacting the Commission for Social Care Inspection. There have been no complaints since the last inspection. The Manager reported that all service users had representatives external to the home. There is information for service users on local advocacy services and all service users are invited to participate in a consultation process with an independent advocacy group, which is arranged annually. The home has adopted the London Borough of Richmond Protection of Vulnerable Adults procedure. In addition, Richmond Churches Housing Trust has its own procedures on abuse and whistle blowing. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 In general, the environment is safe and well maintained, although there are some concerns about heating. There is a pleasant homely atmosphere and service users are able to personalise their rooms. There are adequate facilities available within individual units. Some service users feel restricted by locked internal doors between units. There needs to be further development to support orientation for service users who are confused, so that they become familiar and secure with their environment. The current procedure for washing soiled laundry is not safe and must be changed. EVIDENCE: Accommodation is provided on two floors, accessible by stairways and a passenger lift. There are four interconnected units each with between seven and ten bedrooms, a lounge/diner and a kitchenette. All rooms have en suite facilities and there is a bathroom on each unit. There are two flats at the home, each accommodating one service user. Both flats have a small kitchenette, a shower room and WC. Bedrooms are personalised. There are two attractive, enclosed, level access garden patio areas. Plants, pictures, Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 16 photographs and ornaments throughout the home add to the general ambience. There is a programme of maintenance and bedrooms and communal areas are decorated as needed. The carpet on the first floor is beginning to look worn and would benefit from replacement. The Manager reported that this was due to be replaced during 2006. During 2005, the home was registered to accommodate a greater number of service users who have dementia. Richmond Upon Thames Housing Trust need to consider ways to improve the environment to meet the needs of these service users. Particular attention should be paid to how service users orientate themselves. During the 2005 Advocacy consultation, concerns about the use of digipads on internal doors were raised. Some service users felt restricted by these. A requirement was made at the last inspection that the use of these types of locks was assessed and that action was taken so that service users did not feel restricted, but safety was maintained. No assessment had been made by the time of this inspection and the requirement is restated. The procedures for handling of soiled laundry are not appropriate and staff and service users are put at risk of cross infection. A new procedure, which is designed to reduce risks, must be introduced. Service users on the first floor told the Inspector that the home could become very hot. The Inspector was concerned that the surface temperature of some radiators was excessively hot (Refer to Standard 38 of this report). The Registered Person should consult with service users about the heating and take appropriate action to regulate the temperature to meet their needs. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Procedures for recruiting and supporting staff are appropriate. staffing levels must be reviewed in line with changes to the service. However, The staff must receive further training in dementia in order to understand the needs of service users. EVIDENCE: The staff team is structured into three teams, each led by a senior member of staff and supported by the Manager, Deputy Manager and two Assistant Managers. The staff team is relatively stable and some staff have worked at the home for many years. The staffing structure is well organised and staff demonstrated a good understanding of their roles and responsibilities. The needs of service users at the home are changing and some staff who spoke with the Inspector said that they felt staffing levels were dangerously low. Only two members of waking staff are employed at night. Staff told the Inspector that at times both these staff would be busy helping service users which meant that any one else needing help or support may not get this as quickly as they needed it. Staff on duty told the Inspector that they were also concerned about staffing levels during the day. One unit has three members of staff, two units have two members of staff and one unit has one person on duty. The staff said that this caused problems and meant that sometimes the needs of service users could not be met. This is particularly the case with social activities and some staff said that they did not have the time to support Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 18 service users with these. Care staff undertake some cleaning duties and this takes their time away from service users. The Manager said that this aspect of their role is under review. Staffing levels at the home must be reassessed, taking into account changes in need and activity provision. In general, staff who spoke to the Inspector said that they liked working for Richmond Upon Thames Housing Trust and that they were well supported. The Trust has recently informed all workers over the age of 65 years that they must retire. Staff on duty told the Inspector that this procedure had not previously been enforced and staff over this age had continued working. Some of the staff over 65 years old said that they had regular Occupational Health reviews and did not wish to retire. The organisation should reconsider the implementation of this procedure for existing staff who are fit to and wish to continue working. The organisation has just started work with a new NVQ provider. The Manager reported that this is going well and that seven staff have recently started taking NVQ Level 2. There is a comprehensive programme of training for staff and staff training records indicate a wide range of training. Some staff but not all have received basic training in dementia. The Manager reported that three members of staff are hoping to attend a more in depth course on dementia. It is essential that all staff are skilled and knowledgeable about dementia. Further work to train staff must take place. The requirement made at the last inspection is restated. There is an appropriate procedure for the recruitment of staff including through pre employment checks. The Inspector saw evidence of these in four staff files examined. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 The service is appropriately managed and the management style is open, positive and inclusive. There are appropriate procedures for consultation with service users and staff and for monitoring the quality of the service. There are appropriate procedures to safeguard service users’ money. The staff at the home are appropriately inducted, trained and supervised so that they can care for the service users. Regular checks are made on the environment and equipment to make sure people are not at risk. However, high temperatures from central heating radiators do present a risk and action must be taken to minimise this. EVIDENCE: Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 20 The Manager was being registered with the CSCI at the time of the inspection. She has been in her post since June 2004 and demonstrated a good knowledge of the home and the needs of service users. The Manager is undertaking her NVQ Level 4. Staff and service users told the Inspector that they felt the home was well managed and the Manager was very supportive. Throughout the inspection, the Manager was seen talking to and helping service users around the home. Staff on duty told the Inspector that this was the norm. One staff member said that the Manager was ‘very hands on’ and that ‘she always puts the service users first’. Service users and staff participate in regular meetings and are able to contribute their ideas and thoughts on the running of the home. The organisation arranges for an independent advocacy organisation to consult with all service users and produce a report on their findings each year. The consultation takes place with Advocates speaking individually with service users. They questioned service users about food, activities, staff, the environment, complaints and other facilities. This consultation took place earlier in 2005 and the report was shared with service users, staff, other stake holders and the CSCI. The home does not support service users with general financial management and private arrangements have been made by all service users. Small amounts of cash are held securely by the home so that service users can make minor purchases and pay for additional services, such as hairdressing. There are individual records for all money held on behalf of service users. These are regularly checked and audited. Richmond upon Thames Housing Trust have an approved package of induction for new staff. Staff complete workbooks, a range of basic training and shadow existing staff as part of this induction. All staff receive regular supervision with their line manager. This is evidenced. There are regular meetings for all staff and separate meetings for specific staff groups and senior staff. Minutes of these meetings are held and were examined as part of the inspection. These indicate that the staff are well informed and are able to contribute their opinions. Administrative support is available at the home and records are well organised and accessible. There are regular, well organised and clearly recorded checks on the health and safety of the environment, including equipment and fire safety. There is a range of information for staff to make sure they understand how to maintain good health and safety. Briefing papers about manual handling, fire, Control Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 21 of Substances Hazardous to Health (COSHH) and water safety have recently been issued and discussed with all staff. Some of the radiators at the home were very hot to touch and there is a risk of scalding and possible injury from these. All radiators must be checked and the risks assessed. Action must be taken to reduce the risks of scalding and injury. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 23 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 Requirement The Registered make sure: Person Timescale for action must 31/03/06 1. Photographs of service users are available on the units. 2. Where possible detailed social histories are in place to give staff a better understanding of the individual service users. 2. OP9 13(2) The Registered make sure: 1. 2. Person must 31/01/06 Medication cabinets are securely locked. The amount of individual medication carried from one month to the next is appropriately recorded on medication records. The practice of storing ‘stock’ medication for general use ceases. Version 5.0 Page 24 3. Marling Court DS0000017382.V272860.R01.S.doc 3. OP12 12 13(4) 23(2) The Registered Person must 31/03/06 make sure that the activity programme offers a choice of stimulating activities meeting individual and group needs. Activity participation and enjoyment should be recorded, to support continued development of this service. Previous requirement 30/08/05 4. OP19OP22 12 13(4) 23(2) The Registered Person must: 31/08/06 1. Reassess the environment, in consultation with appropriate professionals. Consideration must be given to how to support better orientation. 2. A full assessment of risk must be developed for the use of locked doors between units, to ensure that these restrictions are only in place where necessary for ensuring safety. Copies of both assessments must be forwarded to the CSCI. Previous requirement 30/08/05 5. OP26 16(2)(e) (k) 23(2)(k) The Registered Person must 31/01/06 review the procedure for handling soiled laundry and introduce new measures to reduce the risk of cross infection and to make sure staff and service users are safe. The Registered Person must 31/03/06 consult with service users about the heating and take appropriate action to regulate the temperature to meet their DS0000017382.V272860.R01.S.doc Version 5.0 Page 25 6. OP25 23(2)(p) Marling Court needs. 7. OP27 18(1)(a) The Registered Person must 31/03/06 undertake a review of staffing levels at the home and must make sure that the needs of service users can be safely met. A copy of this review and action plan must be forwarded to the CSCI. The Registered Person must 31/03/06 make sure that staff are supported to have a better understanding of dementia and the needs of service users, through training, staff discussions, cascaded information and support of professionals. (Requirement made 21.10.04 & 30.10.05 & condition of variation - November 2004) 9. OP38 13(4) 23 The Registered Person must 31/01/06 assess the risks of high surface temperatures on radiators and must take action to reduce risks. 8. OP30 18(1)(a) 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 OP27 Good Practice Recommendations The organisation should reconsider the procedure of enforced retirement at 65 years for existing staff who are fit to and wish to continue working. Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marling Court DS0000017382.V272860.R01.S.doc Version 5.0 Page 27 - 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!