Inspection on 16/06/06 for Marlyn House

This inspection was carried out on 16th June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marlyn House 23/06/09

Marlyn House 29/08/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Marlyn House 41 Cannock Road Blackfords Cannock Staffordshire WS11 2VU Lead Inspector Kathryn Marks Key Unannounced Inspection 16 June 2006 09:30 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 Marlyn House DS0000066241.V306572.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. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlyn House Address 41 Cannock Road Blackfords Cannock Staffordshire WS11 2VU 01543 504009 01543 465750 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) Mrs Renu Ghai Mr Kevin Lawley Care Home 18 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (18), Physical disability over 65 years of age (2) Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: Marlyn House is a detached residential home about a mile from the centre of Cannock, where all services, shops, entertainment, hospital, and transport can be found. The home has its own mini-bus to transport residents to town, or for outings and to entertainment venues. It is a two-storey brick rendered building facing onto Cannock Road, but with ample car parking and domestic garden to the rear. The home provides 24-hour permanent care for up to 18 older people of both sexes, two of whom can have a physical disability, two of whom can have dementia, and four of whom can have a mental incapacity that is neither dementia nor learning disability. The home offers one shared bedroom; all remaining rooms are for single occupancy. Most bedrooms have en-suite facilities and several bedrooms are available on the ground floor. A vertical lift is provided for residents and appropriate toileting and bathing facilities. A large lounge is available with television, and a separate dining area. A loop system has been fitted in the lounge to improve the quality of life for hearing aid users. At the rear of the home patio doors open onto a level garden area where appropriate garden seating and a summerhouse is available. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out on Friday 16th June 2006 between 9am and 3pm. The new proprietor was present in the home and took part in the inspection process. During the inspection the inspector spoke to residents, care staff, cook and deputy manager. All made positive comments about the home and in particular residents about how they are cared for. Two residents were case tracked; both were spoken with, all records relating to them were seen and accommodation visited. Comments received from residents verbally and via written surveys about staff and life at the home and the manner in which they are cared for were of a positive nature: “Sometimes its quiet but we like that” “It’s homely” “I like being in my room” Surveys were also received from relatives and made positive comments about the home. On arrival, residents had completed breakfast and were deciding on their daily routines. On departing from Marlyn House it was observed that the front door was bolted at the top. The Inspector was told this was due to one resident wandering. Arrangements have been made for the Fire Officer to visit the home on Friday 23rd June to advise the new proprietor on an appropriate lock for this door. The Deputy provided written information regarding staffing, staff training, menu and dietary provision that was observed by the inspector to be in place at the home. Residents’ accommodation is located on the ground and first floor; observations of areas that were visited were that the home was clean, generally well maintained and free from odour. Residents’ bedrooms were personalised with favourite items they had brought into the home with them. Marlyn House has in place a Statement of Purpose and Service Users’ Guide to inform residents and relatives of the services and facilities provided; this is being updated to include the new proprietor and all elements listed in schedule 2. All service users have a full assessment of their needs carried out prior to admission to the home. Arrangements are in place for meeting the health and personal care needs of residents and details are recorded in care records. Appropriate recruitment procedures are now carried out and staff, prior to employment, have Criminal Records Bureau and POVA Checks completed. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The Completion of the sale of the home has now taken place and the new Proprietor was on site with the Deputy who is the proposed new Care Manager. The Statement of Purpose and Service Users’ Guide are being updated to include all items in Schedule 1 and the name of the new responsible individual. Privately funded residents contracts are being reviewed and updated to include all elements listed in Standard 2.2 of the National Minimum Standards. The new proprietor is reviewing the provision of activities and considering employing part time activities organiser. Residents meetings have now been started. Large board games and bingo have been purchased, pub lunches are being arranged and the summerhouse is open. Draught excluder has been fitted to bedroom windows in areas where it was draughty and bedrooms felt cool. Quotes are being obtained by the new proprietor for replacement flooring in the kitchen and adjacent corridor. All existing staff now has POVA 1st and CRB checks done, birth certificates photo and declaration of fitness questionnaire are on files. All existing care staff has completed Manual handling training with an external trainer and has certificates. Two new staff and the new proprietor are awaiting places to go. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 7 COSHH cupboard a second key is being cut and staff are to lock cupboard as they take items in and out. 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. Marlyn House DS0000066241.V306572.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 Marlyn House DS0000066241.V306572.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed prior to admission to the home, ensuring that they can be met. Documentation at the home has been updated. EVIDENCE: The Statement of Purpose and Service Users Guide are being updated to include all items in Schedule 1 and the name of the new responsible individual. These documents will be kept under review and updated as required if any changes occur. Contracts of terms and conditions for privately funded residents are being reviewed and updated. All service users prior to admission has an assessment of needs carried out to ensure their individual needs can be met. Inspector reviewed two assessments. Standard 6 is not applicable to the home. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are in place, which ensure that the staff have the information required to meet the service users’ needs. EVIDENCE: Detailed care plans are in place for each service user, and are reviewed on a regular basis. Risk assessments are carried out and were on residents’ files that were sampled. Health care appointments and visits are now all recorded on one sheet, which allows for better monitoring. These contain evidence that medical health professionals are accessed as and when necessary. All residents spoken to during this inspection spoke highly of the staff and the care in the home. Two residents were case tracked care plans were reviewed, both residents spoken to and bedrooms visited. Observation made of medications being appropriately administered; no residents are currently self-medicating. Residents were treated in a respectful way during this visit. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Observations were that residents are encouraged to be independent and are enabled to access the local community. EVIDENCE: Residents said that they were comfortable with the lifestyle they experience at the home music was playing in the one lounge and residents were chatting in the other lounge. The new proprietor has said that she will be looking at employing a part time activities organiser. Within the resident group the deputy identified that there is one resident with dementia. Time is spent with this resident and staff also take her out. The proprietor was reminded of the need to evidence that the needs of diverse group of residents are being met. Meals and mealtimes are to be reviewed with a resident in-house survey being carried out to see if residents want any changes to the menu. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 12 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that service users feel their views are listened to. Vulnerable Adults training is being arranged. EVIDENCE: Marlyn House has a complaints procedure in place this is displayed in the home and contained in the Statement of Purpose and Service Users Guide. Individual residents are provided with a copy of the procedure. At the time of this key inspection there had been no complaints received about the home since the last inspection. The home has in place a book in which to record any complaints and how they are dealt with. Discussions with some residents identified that they were aware of the complaints procedure and if unhappy about something they would talk to the person in charge. Residents are protected from abuse by observations of staff and discussions during staff meetings and supervision. The proposed new Care Manager has been designated to deal with training by the new proprietor and is contacting Adult Protection Team to arrange Vulnerable Adults Training. Policies and procedures are in place at the home. All staff now have POVA 1st and CRB checks carried out; these were sampled on staff files as were staff photographs. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 13 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Marlyn House provides a comfortable well-maintained environment within a very homely setting. Externally, at the rear, there is a large garden and a summerhouse with a choice of seating areas. EVIDENCE: The home generally was clean and well-maintained. Residents’ bedrooms that were visited were very personalised and comfortably furnished. Bedrooms where there was a draught through the windows have had draughtproofing installed. Bedroom six: the new proprietor is reviewing this window and may replace it. To be followed up at the next inspection. To ensure infection control and sustain hygienic conditions the kitchen floor and adjacent corridor floor: the proprietor has said quotes will be obtained and new floor covering will be fitted within one month. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 14 The dining room floor that is stained is to be professionally cleaned; if this does not remove the stains then the floor covering will be replaced. The inspector for the home will follow up the above issues. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are now in place for the recruitment and selection of staff. EVIDENCE: Staff on duty at Marlyn House at the time of this key inspection was observed to be competent and satisfactory in number to meet the needs of individuals in their care. Staff morale was observed to be good with the staff team working well together assisting individuals where needed to make choices to improve their quality of life. Observations today were that staff on duty were as the rota and were sufficient in number to meet the needs of individuals in their care. Procedures are now in place to ensure staff Criminal Records Bureau checks are carried out along with POVA checks prior to permanent employment being offered. The home has a staff-training programme in place and the proprietor has agreed that the deputy who has been designated responsible for training will develop a training matrix. Training updates have taken place or are organised for mandatory training. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 16 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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home has just changed hands and the existing Care Manager is remaining at Marlyn House until a new Care Manager is in place. EVIDENCE: The new proprietor is proposing to put forward the current deputy as the new Care Manager. The deputy has been at the home for four years in the role as deputy and has worked in a caring role at various care homes/hospitals for eleven years. She attends regular training courses to update her knowledge and was familiar with and able to discuss diseases associated with old age. The proposed Care Manager is also doing her Registered Managers Award. Residents are to be consulted and their wishes discussed with them individually by the proprietor and proposed Care Manager. Menu and socialisation are to be reviewed for all residents. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 17 Residents’ finances are dealt with by the resident and family - the home is not involved. The Fire Risk Assessment for the home could not be found at the time of the inspection. A subsequent telephone conversation with the deputy on 21st June confirmed that the risk assessment had been found but as at previous inspection had not been signed. This must be signed to evidence yearly assessment. The fire officer is visiting the home on Friday 23rd June 2006 to discuss appropriate lock for the front door with the proprietor, care manager and deputy. A second key has been cut to enable cleaners who access COSHH cupboard to lock the cupboard when not in use. Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 18 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marlyn House DS0000066241.V306572.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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