Inspection on 22/02/06 for Marlstones Care Home

This inspection was carried out on 22nd February 2006.

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

Marlstones Care Home 16/07/07

Marlstones Care Home 24/07/06

Marlstones Care Home 15/10/05

Marlstones Care Home 18/03/05

Marlstones Care Home 01/06/04

Marlstones Care Home 17/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Marlstones Care Home Adgate Close off Rock Street Bulwell Nottingham NG6 8QU Lead Inspector Rob Cooper & Rehana Rashid Unannounced Inspection 22nd February 2006 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 Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 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. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marlstones Care Home Address Adgate Close off Rock Street Bulwell Nottingham NG6 8QU 0115 9270629 0115 9760452 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) Nottingham City Council Mrs Cecilia Broughton Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 8 service users may be under the age of 65 years, but over 55 years 15th October 2005 Date of last inspection Brief Description of the Service: Marlstones is residential care home for older people, owned and managed by Nottingham City Council. It is located to the north west of the city centre in the Bulwell area. The building covers two floors, with the upper floor being accessed either via a staircase or a passenger lift; as a result people with restricted mobility can be accommodated. Marlstones is currently registered for forty-eight places of which four might be emergency/ short term care beds. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection lasted approximately three hours with two Inspectors present. The methodology used was to visually inspect the premises, talk with two members of staff, check a wide range of records, and policies and procedures and ‘case track’ three residents. This involves looking at a selection of care records, and making a judgement about the quality of care being offered, and received. The overall impression is of a well-run service, happy and well cared for residents, and a good quality environment. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 6 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 Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 7 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): 12&6 Prospective residents do not have all of the information they need to make an informed choice about coming to live at Marlstones. Residents at Marlstones do not yet have a written contract/ statement of terms and conditions of residence. Residents coming to Marlstones for short-term care are helped to maximise their independence. EVIDENCE: At the last Inspection it was set as a requirement that the welcome pack, which incorporates the Statement of Purpose and Service User Guide, should have contact details for the Commission for Social Care Inspection. This has still not been completed. In addition it was set as a requirement that the terms and conditions of residence including any fees, and method of payment should be included in the Service user Guide. This too has not yet been achieved. Marlstones offers short term and emergency beds (four) rather than all out Intermediate care. Residents filling these beds have their needs assessed, and are offered appropriate levels of support toward achieving independence. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 8 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 & 10 Residents at Marlstones do have their health; personal and social care needs set out in an individual plan of care. Residents feel they are treated with respect and their dignity is upheld. EVIDENCE: At the last Inspection one requirement and one recommendation were set relating to individual plans of care. These related to reviewing care plans on a monthly basis. The three resident’s files that were seen, all showed that care plans are being reviewed on a monthly basis. During the Inspection the staff were observed talking with residents, and this was seen to be in a polite and respectful manner. There were two specific examples where the manager spoke to residents, and these were particularly polite, and respectful communications. However a number of the bathrooms did not have window blinds, and while these windows had opaque glass, and in many cases are not directly overlooked, and are on upper floors, window blinds will enhance residents feelings of privacy, and should be fitted to all bathroom windows, whatever the circumstances. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 9 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 Residents do find that the lifestyle they experience matches their cultural, social and recreational needs. Residents do receive a wholesome appealing and balanced diet. EVIDENCE: At the last Inspection it was recommended that the level of entertainment be reviewed. Evidence from care plans and notice boards – showing planned and forthcoming events and activities, suggest that this has been done. The kitchen was inspected, and meat and potato pie was being prepared for the main option for lunch. There were alternatives, and records seen in the kitchen showed who opted for any alternative choice of meal. The menu was seen. And this provided ample choice, and healthy options for eating. There was a range of fresh vegetables and tinned and dried options, and storage of foodstuffs was correct. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 10 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 Residents and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Resident’s legal rights are protected. Residents are protected from abuse. EVIDENCE: The complaints policy was prominently displayed throughout the building, and the Marlstones complaints records were seen, with the last complaint having been received in February 2006. The records showed that this complaint was dealt with in line with the policy, and within the specified time frame. All residents are registered for a postal voting, and records in files recorded this fact. Staff training records show that a Protection of Vulnerable Adults course was held in-house on the 31st January 2006. Risk Assessment training is booked for the 3rd March 2006. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 11 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): 22 23 24 & 25 Residents at Marlstones do have a wide range of specialist equipment to maximise their independence. Resident’s bedrooms do suit their needs, and bedrooms are safe, comfortable and have resident’s personal possessions in them. Residents at Marlstones do not live in safe surroundings. EVIDENCE: A visual inspection of the building revealed a passenger lift to access the upper floor. This lift is a talking variety, which announces to passengers the floor level reached, and identifies when the doors are opening and closing. In addition there were raised toilet seats, and ample grab rails and bars to assist with mobility and safety. There is a range of bathing options, with walk-in showers, and whirlpool baths. Several bedrooms were seen; these were comfortable and well personalised. Following previous Inspections radiator covers/guards have been purchased. These are being stored within Marlstones, but as yet have not been fitted to cover any of the radiators within the building, which potentially leaves residents at risk. Standard 25.5: ‘Pipe Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 12 work and radiators are guarded or have guaranteed low temperature surfaces.’ These radiator covers should be fitted as soon as possible to enhance resident’s safety. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 13 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): 29 Residents at Marlstones are supported and protected by Marlstones’ recruitment policy and practices. EVIDENCE: Marlstones’ recruitment follows City Council policies and procedures. Two staff files were seen, and these contained the information and employment checks required by Care Homes Regulations. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 14 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 & 35 Marlstones is run and managed by a person who is fit to be in charge, and of good character. Resident’s financial interests are safeguarded at Marlstones. EVIDENCE: The manager has 25 years experience of working in care. She is a State Registered Nurse, and a Registered Mental Nurse. In addition she has a Diploma in Social Work, has undergone leadership training and periodic job specific and mandatory training. During the Inspection the manager was seen talking to residents with compassion and care. Residents or their families are in control of resident’s finances as appropriate, although small amounts of cash are held in the office. These ‘small needs’ cash amounts were seen and checked, and records seen and also checked. All expenditure is receipted, and there is a clear audit trail. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 15 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 2 2 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X 4 3 3 2 X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X 3 X X X Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 16 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 OP1 Regulation 5 (1) f Requirement The Registered person shall produce a written guide to the care home which shall include: the address and telephone number of the Commission (CSCI) Outstanding from last Inspection: 15/11/05 2. OP2 5 (1) b The Registered person shall produce a written guide to the care home which shall include: the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees. Outstanding from last Inspection: 15/11/05 3. OP25 13 (4) a 30/06/06 The Registered person shall ensure that all parts of the home to which residents have access, are so far as is reasonably practicable free from avoidable risks. The radiator covers, which have been purchased and are being stored within Marlstones, DS0000037295.V282492.R01.S.doc Version 5.1 Page 17 Timescale for action 31/05/06 31/05/06 Marlstones Care Home should be attached to the radiators in the building. 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. 2 Refer to Standard OP10 OP38 Good Practice Recommendations The Registered person should ensure that window blinds are fitted to all bathroom windows, even those that are not over looked. The Registered person should ensure that daily refrigerator temperatures in the bar area are recorded. Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Marlstones Care Home DS0000037295.V282492.R01.S.doc Version 5.1 Page 19 - 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. 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