Inspection on 06/11/07 for Marlowe House

This inspection was carried out on 6th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Marlowe House 23/09/09

Marlowe House 18/10/08

Marlowe House 06/06/06

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Marlowe House School Lane Hadlow Down East Sussex TN22 4HY Lead Inspector Debbie Sullivan Key Unannounced Inspection 6th November 2007 09:50 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 Marlowe House DS0000066431.V353132.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. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlowe House Address School Lane Hadlow Down East Sussex TN22 4HY 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) 01825 830224 01825 830924 AUM Care Limited Mrs Janet Moseley Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is 20 (twenty). Service users must be older people aged sixty-five (65) years or over on admission. 30th November 2006 Date of last inspection Brief Description of the Service: Marlowe House Residential Home is registered to accommodate up to 20 older people. The home is a substantial detached property that has been converted and extended for its’ current use. It is situated on the outskirts of Hadlow Down village near the town of Uckfield. The home is arranged over three floors, service users accommodation is provided on the ground and first floors and staff accommodation is on the second floor. There is a chair lift and two staircases between the ground floor and first floor. The home provides fourteen single and three shared rooms, has a conservatory, dining room, two lounges - one on the ground floor and one on the second floor and a well-kept garden with some seating and off road parking. The majority of the staff team are well established at the home. In house activities are provided for service users such as motivation sessions and quizzes. Fees are assessed on an individual basis and range from £355 to £500 per week. Additional charges include hairdressing and chiropody. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection of Marlowe House took place over nearly seven hours. During the visit time was spent with service users, staff and the registered manager. The home was toured and a range of records and documentation including some policies and procedures, care plans, staff records and medication records were read. Service users were joined in the dining room at lunchtime and throughout the visit were very helpful in contributing to the inspection. Survey forms sent in to the Commission by service users, staff and relatives were helpful in providing additional information. The Commission had not yet received the Annual Quality Assurance Assessment Document for the service, the manager was preparing it and it was well within the timescale for return. Information supplied in the AQAA will help to inform the next inspection. A pharmacy inspection took place in November 2006 with good outcomes overall, two requirements that were made have been met. What the service does well: The needs of service users are assessed prior to admission and care is taken to ensure that they can be met in full before a place is offered. Care plans give a good picture of service users as individuals and the service aims to provide as far as possible a personalised service where the preferences and personalities of service users are respected and valued. Good health is promoted and the home has good links with health professionals. Meals are well-cooked, varied, nutritious, prepared using fresh ingredients and service users are very complimentary about them. Staff are genuinely interested in providing service users with a good standard of lifestyle and care, and work hard to offer activities and find time to spend with people individually. Service users speak very highly of staff and staff say they like working at the home. The management of the home is open and inclusive. The home has a warm and friendly atmosphere that service users and relatives appreciate. The manager is approachable and experienced in working at the home. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Marlowe House provides a caring and friendly home with a good standard of care and dedicated staff; unfortunately sufficient importance has not been given to investing in staffing, some aspects of staff training and the environment. This is beginning to impact on the overall level of service and although service users say they are satisfied, staff and relatives have expressed concern over staffing levels and the décor. Investment must be made in refurbishing the building, in some areas such as in bathrooms and where there are loose carpets there are health and safety risks for service users and staff; action must be taken to remove risks. Staffing levels do not allow for each service user’s needs to be fully met when the home is full or nearly full and staff are frustrated at not having enough time to offer more activities. Staff need to be offered the opportunity to enrol on NVQ in care training at an appropriate level to further their learning and to meet the requirement of 50 NVQ trained staff employed. Staff must have adult protection training to raise their awareness of adult protection issues and any potential adult protection alerts must be raised with social services. All staff administering medication must adhere to the proper procedures. Any complaints from service users or staff must be properly recorded and the provider must submit Regulation 26 reports to the manager following unannounced monthly visits. Marlowe House DS0000066431.V353132.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. Marlowe House DS0000066431.V353132.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 Marlowe House DS0000066431.V353132.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. Potential service users are able to access information about the home before making a decision to move in and their needs are fully assessed before a place is offered. EVIDENCE: The home has a statement of purpose and service users guide; these are now made available to prospective service users and their families, and service users or their representatives are informed of the offer of a place in writing. Minor amendments are needed to the service users guide to bring it up to date. The manager carries out an assessment of each potential service user and in the case of social services funded service users is provided with their Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 10 assessment as well. The manager discussed the need to assess thoroughly to make sure that the home can meet needs and said that currently all the service users were appropriately placed. Following admission there is a trial period of three months before a place is made permanent. Service users spoken with said that they or a relative had visited the home before they moved in and one said they had chosen it over others viewed due to the homely atmosphere. A survey form from a service user stated that they initially had a trial stay at the home before moving in permanently and they have not regretted their decision to stay. Service users felt that the home met their needs. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans reflect in detail the needs of each service user and are well maintained. Health needs are well met and any concerns referred to health professionals. Medication recording and procedures are improved overall, whilst all staff need to fully adhere to procedures. EVIDENCE: Each service user has a care plan; three service users were case tracked and their care plans were read. Information was available on the service users’ Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 12 backgrounds and interests, there is detailed information on preferences and care plans are being reviewed monthly. Daily recording is included; entries are appropriate and include information on family contact and activities. Health input and appointments are well recorded and there is the opportunity for service users to record their wishes in the event of terminal illness and death. The manager said that the home has good links with the local GP surgery and other health professionals, if staff need advice on a specific health matter health professionals provide it. Any concerns about health or emotional needs are swiftly referred on and the manager and a staff member spoke of recognising that a service user was recently affected by the deaths of two other service users and support over this had been sought. Since the last key inspection a pharmacy inspection took place on 30th November 2006, the findings were that service users are supported if they wish to self medicate. Staff were to be retrained in medication procedures, written medication policies and records were good and storage was good. Requirements were made in respect of the need to have more detailed PRN guidelines and that recording on MAR sheets needed to be improved upon, these requirements are met. There are now detailed PRN guidelines in place. The manager discussed a medication concern that had arisen quite recently, and was advised inform social services about it as a staff member had administered a medication unnecessarily. MAR sheets examined were in order and staff confirmed they had had medication training. Throughout the visit staff attended to the personal care needs of service users discreetly and privacy and dignity were respected. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 13 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. Service users are offered opportunities to take part in activities at the home their contact with relatives and friends is promoted. Meals are well cooked, nutritious and varied. EVIDENCE: Service users spoken with during the visit and who sent in survey forms expressed a high level of satisfaction with the lifestyle that they experience at the home. It was clear that this is mainly due to the efforts of the manager and staff in providing a homely atmosphere, involving service users, providing activities and finding time to spend with people individually even though when the home is full staff can be pushed for time. A variety of activities are offered such as quizzes and bingo, karaoke and motivational sessions given by outside providers. The local school is very nearby and has good links with the home and the vicar takes a monthly Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 14 service, which is well attended. A service user who requested their own vicar is visited by him regularly. Staff offer manicures and a hairdresser visits weekly, she was at the home during the inspection and very popular. It was a pleasant day and two service users were spending time in the garden in the patio area and one was taking a regular walk round the grounds. The manager said that the garden is well used all year round and one service user likes to help with gardening. In the summer the home had held a garden fete and a barbeque. All the service users spoken with said they were satisfied with activities with one commenting they would like to go out more. Staff and the manager felt that they would like to offer a lot more activities and outings although currently there is no additional funding for outings and no available transport. Contact with friends and relatives is promoted, one service user went out to lunch with a relative and others spoke of regular visits. Service users have choice and control over their lives and are able to choose when to get up, what to wear, what to eat and to stay in their rooms if they wish or spend time with others. One service user spoken with said they prefer to spend time in their room due to health reasons and their wish to get up quite late was respected. Service users were joined at lunchtime, the meal was tasty and well cooked using fresh ingredients, service users said how much they enjoyed the meal and were complimentary about meals overall. Comments included “the meals are very well cooked and well presented, varied and very tasty” and “Food delightful and adjusted for minor problems (allergy)”. There is choice if service users do not like the main option and the cook prepares home made soup, other savouries and cakes for the evening meal. The emphasis is on using fresh ingredients and good nutrition. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users have access to a complaints procedure and feel confident that they can raise concerns with staff and will be listened to. Staff need to acquire more knowledge of adult protection so that service users are more fully protected. EVIDENCE: The home has a complaints procedure and service users spoken with said that they would speak to the manager if they had any concerns and would feel confident that they would be dealt with, although they said in person and on survey forms that they had no complaints. One formal complaint by a relative had been made since the last inspection and had received a written response from the provider but needed to be recorded in the complaints book. There is an adult protection procedure that would benefit from some revision to bring it up to date and make it more accessible for staff. Staff are subject to a CRB and POVA check prior to starting work at the home, Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 16 Staff have not had adult protection training although those spoken with had an awareness of what constitutes abuse and felt that they would feel confident in raising any concern. The need for an adult protection alert to be raised in relation to a staff medication practice concern was raised during the inspection, as an unnecessarily administered medication had caused discomfort and distress to a service user. Following receipt of the information the social services adult protection coordinator decided to record the information but not investigate. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment is poorly maintained and there is no evidence that there are any plans for investment in improvements. Furnishings are of poor quality and some areas present a health and safety risk. EVIDENCE: The home offers accommodation over two floors and those with the most mobility needs are accommodated on the ground floor as far as possible, there is new stair lift and the last key inspection identified that all areas of the home Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 18 had been made more accessible for service users since the home had been under new ownership. The building is attractive and bedrooms are of differing shapes and sizes, the majority of the bedrooms were seen and each had been personalised by service users, some had brought furniture from home and most had brought pictures, photographs and ornaments. The building was cleaned to a good standard throughout although there has been a sustained and noticeable lack of investment in the fabric of the home, furnishings and décor and it generally looks shabby and much in need of refurbishment. Service users spoken with liked their rooms, although some bedrooms have flaking paintwork and peeling wallpaper, one ensuite has a rusty radiator cover and carpeting is worn and loose in places. There are two downstairs and one upstairs bathrooms; only one downstairs bathroom is in use, the other being used for storage. In the used bathrooms both baths need resurfacing or replacing, the rooms need redecorating as there is flaking paint and damaged woodwork and in the upstairs bathroom the bathseat rail cover is peeling. Some upstairs corridor areas are dark posing a risk to those with poor sight. Areas of carpet in bedrooms and communal areas are stained, staff advised that the annual deep cleaning of carpets that used to take place is no longer arranged. The communal areas are the downstairs lounge and dining room, a pleasant conservatory and an upstairs lounge. Again all are clean and comfortable but shabby and furniture and furnishings do not match. Staff spoke of on occasions doing some decorating and of buying items for the home personally such as pictures and crockery as there is insufficient funding made available for good quality items to be purchased. The commitment of staff to improving the environment is commendable but it is unacceptable that they feel they have to take these measures and the provider must provide sufficient good quality furnishings and equipment. No handyman or gardener is now employed, so again staff both on and off duty sometimes undertake minor repairs or do gardening, this a poor use of already compromised staff time and properly qualified maintenance staff must be made available. The drive has been tarmaced to make it safer but the path leading from the driveway remains unsafe and uneven for service users, this is a repeated requirement. Items of equipment and furniture are stored throughout the home and are unsightly or could prove a hazard; the provider must make suitable arrangements for their disposal or storage. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 19 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 well supported, confident in their roles and like working at the home. Staff are not offered opportunities to gain an NVQ and staffing levels do not always allow for service users needs to be fully met. EVIDENCE: The staff team comprises of the manager, deputy manager, three senior carers, carers, a cook and cleaner. The post of senior carer has recently been introduced to help clarify lines of accountability. Staff files were sampled and contained the necessary recruitment documents. Two care staff are on duty on each daytime shift with one waking and one sleeping member of night staff. The home had several service user vacancies when the inspection took place and staff felt that this allowed for them to have time to chat to service users and they were not rushed. Although when the Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 20 home is full they felt time was at a premium and there should be a third carer on shift. The provision of a third carer at all times on daytime shifts would also allow for service users to be taken out more frequently. The comments from service users and relatives on survey forms and from service users in person were very positive regarding the attitude, attentiveness and professionalism of staff although some survey forms reflected that there were not always enough on duty to meet individual needs. Positive comments included “Staff are always happy, caring and supportive and create a relaxed homely atmosphere” and “I couldn’t be looked after better”. The cleaner has experience of caring at the home and uses some hours to cover peak times in the morning and covers when there are staff shortages. This reduces cleaning time, which is not satisfactory, and in addition the two staff on duty at weekends do the cleaning, as there are no weekend domestic staff employed. The provider must employ sufficient care and domestic staff as the needs of service users and the cleanliness of the building is being compromised and there are insufficient staff to cover for any absences and to meet needs in full when the home is fully occupied. Staff spoken with liked working at the home and the team remains fairly stable with little turnover. Staff felt well supported by the manager and deputy manager and they have regular supervision. It is a recommendation that supervision recording be more through and records personalised for staff. Staff receive training provided in house and by external providers, updates are arranged for mandatory topics such as first aid and manual handling but there is a need for adult protection training to be arranged. The home has not met the target of having at least 50 of staff employed by the home trained in NVQ care at level 2 or above. The provider is not making the funding available for staff to enrol on NVQ’s at a level appropriate to their experience and training already obtained, even though it is a requirement that sufficient staff have the qualification. Staff observed during the visit were confident and competent and related well to service users, it is disappointing that a dedicated staff group who are committed to providing a good service and remain with the home are not offered the opportunity to progress and gain an NVQ. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an open and friendly atmosphere and the views of service users are sought. The health, safety and welfare of service users and staff are being put at risk by poor investment in the environment and staffing. EVIDENCE: Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 22 The manager of the home is well qualified and has managed the home for a number of years. The management style of the home is open and inclusive and staff and service users say that the manager is approachable. The manager promotes the provision of a personalised service in which service users feel they can make their views known and make choices. The views of service users and of relatives who returned survey forms were very positive about the about the welcoming and warm atmosphere and the care provided. A relative commented, “The friendly and relaxed attitude of staff contributes to a very warm and friendly atmosphere for residents and visitors”. The manager and staff work hard to provide service users with a good quality of life and care although the standard of the service overall is reduced by a lack of investment in the home, especially regarding the environment. The health, welfare and safety of service users and staff are put at risk by the risk of cross infection caused by poor upkeep of bathrooms and some other areas. The standard of record keeping is good and records are kept safely and securely. The views of service users are sought, as are those of relatives and health professionals, service users felt that they had plenty of opportunity to speak with the manager. The manager said that the provider visits the home at least once a week and is supportive; Regulation 26 and visit reports are not being completed, this is a repeated requirement. Health and safety checks take place and since the last inspection fire procedures have improved with an individual fire evacuation assessment being put in place for each service user. Staff are trained in fire safety and when training takes place at the home if service users wish they can sit in. The manager speaks with them about fire evacuation procedures to make sure they are aware of action that would take place if there were a fire. Water temperatures were in order and whilst fridge sand freezer temperatures were being taken they were not recorded, the manager took action during the visit to make sure they are in future. The home has valid insurance in place. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 23 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 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 2 1 X 3 2 1 2 STAFFING Standard No Score 27 2 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 X 3 3 2 Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 24 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 OP9 13(2) Regulation Requirement “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home” In that all care staff must adhere to the homes’ medication policies and procedures in full at all times. Care staff must not give any medication that is not prescribed or PRN medication that is not necessary. 2. OP12 16(2)(m) “The registered person shall consult service users about their social interests, and make arrangements for them to engage in local, social and community activities” In that there must be sufficient staffing, funding and transport made available for service users to be able to access the local community and for more activities within the home. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 25 Timescale for action 30/11/07 30/01/08 3. OP16 17(2) Schedule 4 (11) “The registered person shall 30/11/07 maintain in the care home a record of all complaints made by service users or representatives or relatives of service users or by persons working at the care home” In that all verbal or written complaints must be fully recorded in the complaints book with information on the response made. 4. OP18 13(6) “The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse” In that all staff employed by the home must have adult protection training and any incidents of suspected abuse must be promptly referred to social services. 30/12/07 5. OP19 13(4)(a)(c “The registered person shall ) ensure that all parts of the home to which service users have 23(2)(b)( access are free from hazards to d)(o) their safety, and unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The registered person shall ensure that the premises are of sound construction and kept in a good state of repair externally and internally, the care home is kept clean and reasonably decorated, and external grounds are safe for use by service users.” 30/01/08 Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 26 In that a programme of routine maintenance and renewal of the fabric and decoration of premises is produced and implemented with records kept, stating timescales. This requirement is repeated from the last key inspection. The home must be refurbished to an acceptable standard and hazards such as loose carpets, peeling and flaking paint and wallpaper, rusty radiator covers, an damaged bath surfaces and the damaged bath seat must be replaced. Stained carpets must be replaced or industrially cleaned. It is a repeated requirement that the path outside be made safe for service users. 6. OP19 23(2)(l) “The registered person shall ensure that suitable provision is made for storage for the purposes of the care home” In that old or unused furniture or equipment must be safely stored or removed. 7. OP21 13(3) “The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home” In that bathrooms must be repainted and woodwork repaired where there are gaps and it is damaged. Baths must be resurfaced or replaced and the bath seat replaced. Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 27 30/12/07 30/12/07 8. OP27 18(1)(a) “The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users” In that three members of care staff must be on duty during each daytime shift to ensure that the needs of all service users can be fully met. Cleaning staff must be employed at weekends. Gardening and maintenance staff must be employed. 30/01/08 9. OP28 18(a)(c)(i )(ii) “The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users and that the persons employed to work at the care home receive training appropriate to the work they are to perform and suitable assistance, including time off to obtain further qualifications appropriate to such work” The home must employ the required 50 ratio of staff trained at NVQ level 2 or above 30/01/08 Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 28 care and demonstrate a commitment to promoting NVQ training. 10. OP33 26 (2)(4)(a)( b)(c) “Where the registered provider is an individual, but not in day to day charge of the care home, he shall visit the care home unannounced at least once a month and supply a copy of the report required under paragraph (4)(c) to the registered manager.” In that a report must be provided monthly to the manager and be available for inspection. 30/11/07 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 OP1 Good Practice Recommendations It is recommended that the statement of purpose be amended to give up to date information on details regarding CSCI and relevant contact details. It is strongly recommended that a list of care staff qualified to administer medication be included in the MAR sheet folder. It is recommended that all daily meal choices be fully recorded for each service user. It is strongly recommended that the homes’ adult protection procedures be reviewed and updated. It is recommended that the garden be made tidier and therefore safer for service users. 2. OP9 3. 4. 5. OP15 OP18 OP19 Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 29 6. OP36 It is recommended that supervision be recorded in more detail and recording be more personal to the staff member. It is strongly recommended that fridge and freezer temperatures be recorded on a daily basis. 7. OP38 Marlowe House DS0000066431.V353132.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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