Inspection on 29/08/07 for Marlyn House

This inspection was carried out on 29th August 2007.

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

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

Other inspections for this house

Marlyn House 23/06/09

Marlyn House 16/06/06

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 5BU Lead Inspector Mr Keith Jones Unannounced Inspection 29th August 2007 09:00 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 Marlyn House DS0000066241.V343883.R02.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.V343883.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlyn House Address 41 Cannock Road Blackfords Cannock Staffordshire WS11 5BU 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 Denise Philomena Seymour 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.V343883.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 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.V343883.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, by one inspector, the Registered Provider and Care Manager, with senior staff assisting, in a professional and cordial atmosphere. The Inspector acknowledged receipt of the prepared Annual Quality Assurance Assessment and 11 comment sheets, all complimentary with some useful advice. Comments received from residents and families, via written surveys about staff and life at the home, and the manner in which they are cared for were of a positive nature: “Can find no fault”, “I get lots of attention”, “Spotlessly clean, staff kind and considerate”. Surveys were also received with comments about the home’s services, activities and décor, none were over critical, and all were shared with the management. The last inspection report was discussed, and it was noted that there were no outstanding requirements or recommendations. On the day of inspection there were 18 Service Users in residence. A full case tracking of Three Service Users yielded a valuable insight of policies in action. Records had been correctly filed and stored, with a sample review of the administrative arrangements confirmed effective management. Weekly fees range from £344 to £370. Plans have been submitted for Council approval for an extension to increase the beds available to 20. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of residents, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. A review of the administrative arrangements confirmed solid practice and effective management. A full verbal report was offered at the end of the inspection to the Provider and Care Manager. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: The Home offers a genuine commitment to care with an open and personable approach, which reflects the homeliness of a confident relationship between carer and resident. The establishment of a professionally accountability towards effective assessment, care planning and review of resident’s needs are meaningful and robust, in formulating a good standard of care. This highly Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 6 personable attitude and approach to care is appreciated and welcome by residents and visitors alike. The management demonstrate a professional approach in maintaining an environment conducive to the care of the elderly. There is a constant appraisal and review process of facilities and services to maintain that environment. What has improved since the last inspection? What they could do better: The Home has demonstrated a commitment to caring for the elderly with good standards, which need to be maintained. Attention needs to be focused on improving the administration and management of medicines. The imminent upgrading programme needs to encompass the provisions of Regulation. Further work into providing the principle of partnership of care with family and resident, will continue to build on a very positive attitude and established practice. Please contact the provider for advice of actions taken in response to this Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 7 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. Marlyn House DS0000066241.V343883.R02.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.V343883.R02.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 The quality in this outcome area is good Marlyn House ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. The Provider ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. The Home has demonstrated their commitment to promote a partnership of care, to meet the objectives of providing a home to meet individual needs. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 10 EVIDENCE: The Statement of Purpose and service user’s guide represent a good description of the home’s aims and objectives, philosophy of care and terms and conditions, offering service users and their relatives the opportunity to make an informed choice about where to live. All the requirements prescribed in Schedule 1 are addressed. The document is to be kept under a consistent review to reflect changing circumstances and management arrangements. It is clearly stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also clearly indicates the terms and conditions, which are discussed with service users and relatives prior to admission. A review is necessary to reflect continuing changes in managerial and environmental circumstances. The contract document reflects changed circumstances and conditions, which should include an identification of allocated bedroom agreed. A pre-admission assessment, always carried out by a senior member of staff appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on a daily living process. The Home demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The registered person also makes a judgement as to the suitability of each prospective service user using the same criteria. Marlyn House DS0000066241.V343883.R02.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 The quality in this outcome area is good. The service users’ assessment provides the base, from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has access to a number of GPs that visits the Home frequently, and the majority of service users are registered within 48 hours. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of essential mutual trust and respect. The provision of a secure and safe medicines administration is managed effectively, although recording of creams and ointments administered require review. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 12 EVIDENCE: There was evidence to show that a review of the care process has produced a satisfactory standard of meeting care needs. The pre-admission assessment represents the foundation for an informative care planning process. Three residents’ care files were tracked and demonstrated a system of detailed information on the individual, their life style and needs, events and contacts, procedures and actions measured on a daily basis and reviewed monthly. The policy of the Home is to maintain service users own GP support wherever practical; otherwise residents are registered with the local surgery. District nursing services are also received, and the home has an established and positive professional rapport. Paramedical support is openly obtained when necessary. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. “ Very good care on all fronts”, ”I get lots of attention, the staff are kind and considerate” were some of the comments offered by residents. There was evidence that suitable equipment was deployed effectively. Carers were seen to interact with residents with purpose and compassion. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. The administration of medicines adhered to procedures to maximise protection to service users. The storage was secure, with satisfactory added security for controlled drugs. The use of a drugs trolley should be pursued to improve administration procedures. The record of administration of systemic medicines was satisfactory, although a less cumbersome approach to administering prescribed creams and ointments would enhance control. A controlled drug register was examined and found to be up to date. The Care Manager was advised to obtain a formal register from the pharmacy supplier. The MAR sheets would be more presentable with a front divider with resident’s photograph and relevant information on it. Staff training has been extensive over the past 12 months, undertaken by Boots, and continues to be pursued actively by the Care Manager. It was advised to establish a list of recognised carers, with specimen signatures. There was one resident self-medicating at the time of inspection. Each service user has the opportunity of their own lockable facility in their bedrooms on request. The procedure for handling accidents and incidents was inspected and found to be satisfactory. Reports were informative, detailed and meaningful. However the recording and archiving of reports needs a review, to ensure protection of Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 13 information. The Care Manager was advised to analyse accidents on a 3 monthly basis. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. There was also an observed knowledgeable, and positive attitude by staff towards residents, and feedback from the residents: “ Can find no fault”, “ could do with more activities”, and “excellent care, décor could be improved”. Regular family/resident forum meeting are proving to be useful and have helped to improve communications and understanding. Questionnaires are sent out regularly to reinforce the importance of consultation and involvement. It is anticipated that this exercise would continue on a six-monthly basis. The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out. The spiritual needs of service users were recorded and observed by the staff, with due respect. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Service users’ life-styles and interests are recorded in their care plan, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Personal choice and relative self-determination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. Service users were offered a varied and nutritious choice of meals from a 4week rotating menu. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 15 EVIDENCE: Discussions with Residents and staff clearly identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. Service users’ life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. This principle was supported by a part-time activity co-ordinator who has established a climate conducive to enhancing social awareness. The recording of social activities was seen to be a valuable part of care reporting and planning. A varied menu is available for service users on a four-week cycle and represent a wholesome, appealing and varied balanced diet. Lunch was served during inspection and meals seen to be wholesome and nutritious with service users enthusiastically agreeing on the quality of preparation and serving. Special dietary needs are catered for and monitored as was evidenced through case tracking. Some service users choose to have their meals in their bedrooms. The dining areas were very pleasant, offering a conducive ambience for a social meal. Staff were seen to offer discreet assistance to those who required it. The kitchen was seen to be clean, well organised and with modern equipment. Fridges/freezers and food temperature records were examined and a cleaning schedule was in place. All records need to be completed on a daily basis, to evidence the high quality observed. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The home has systems and procedures and to protect residents from abuse. EVIDENCE: The complaints policy was seen and records examined. There were few complaints, none recent, to assess. All service users had received information on the procedure to complain, including reference to the CSCI. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. A small complaints book would enhance quality control on this issue. Case tracking confirmed the effectiveness of a Provider, Care Manager and staff sensitive to service users needs and readiness to test the robustness of their information and report structures. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. This process was evidenced on examination, and case tracking as previously reported upon. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 17 The care management showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The quality in this outcome area is good. This judgement was based on discussions with service users, staff and a tour of the premises. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. On inspection, bedrooms were personalised, with most displaying service user’s own furniture, and with personal belongings. All communal areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a very high standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 19 EVIDENCE: A tour of the Home, service departments, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy, and were being well maintained. The surrounding garden areas were well maintained providing a pleasant area for relaxation and a summerhouse available in warmer months. Internal access was facilitated with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. On admission the Provider or Care Manager assesses each individual service users’ needs for equipment and necessary adaptations. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be pleasant. There is a need to fix a permanent safety gate at the head of the stairwell. All stores need to be secured when not in use. The home provided lounge areas that were pleasantly decorated providing essential furnishings and items to provide comfortable areas where residents were able to interact with fellow residents, or to entertain their guests. There was a pleasantly furbished dining area where service users were able to dine in comfort. Toilets and bathrooms were located on both floors and were in close proximity to bedrooms and communal areas. One bathroom has been converted as a shower area. It was advised to address privacy signs on toilet and bathroom doors. Bedrooms were well maintained to meet service user’s personal preferences. On inspection, most bedrooms were highly personalised, with some displaying service user’s own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. There is throughout a satisfactory standard of furnishing. Several wardrobes were seen unattached to security mountings. Nevertheless service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Several windows remain poorly fitted to maintain ventilation with safety. An effective call system is installed; care staff reacted speedily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. A locked facility and lockable bedroom doors are made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 20 Kitchen presentation showed good standards of cleanliness and evidence of sound food hygiene practices. Maintenance of records need to reflect the good standards observed. The small laundry was organised and equipped to a good standard. Consideration to the flow of laundry through the process would enhance cross infection control. Red Alginate linen bags are available and widely used. Notices regarding chemical handling in the areas that store chemicals are displayed. It is recognised that a new laundry is planned for in the extension aims. The external and internal environment was well maintained and secure. The Care Manager (designate) is to provide the Inspector with a development plan for 2007/08/09. Heating and ventilation were found to be satisfactory and lighting was domestic in style. Aids, adaptations and equipment were available throughout the Home. Fire equipment was inspected and seen to be serviced and up to date. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 21 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 The quality in this outcome area is adequate. Staffing levels were seen to be adequate to meet an expected demand, the daily care staffing rota showed adequate balance between skills and qualifications although it has been recognised that for several hours a day there are shortages of staff. The Provider and Care Management have established a procedure for interview, selection and appointment of staff, which requires reinforcement in ensuring the protection of service users. Staff training records need to complement the effort placed into staff training. EVIDENCE: Three weeks of shift rotas were examined, and showed an adequate balance between skills, qualifications and numbers to provide a foundation for a solid standard of care. However there were times when staffing levels fell below recommended levels, to which the Care Manager had planned to increase hours to remedy this situation. The Care Manager is supported by an able team of carers. Overtime and flexible rostering are used to meet shortfalls. Agency staff are rarely used. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 22 At the time of inspection the duty rotas confirmed a staff coverage as thus: a.m - 1 senior 1 carer p.m - 1 senior 1 carer N.D - 1 senior 1 carer It was agreed that there should be an increase of care staff by 28 hours a week to meet immediate needs, with a further28 hours on completion of the extension. There is a satisfactory complement of housekeeping/laundry staff, and a satisfactory establishment of catering staff. The Provider and Care Management have established a procedure for interview, selection and appointment of staff. Three staff files were sampled and found to be generally well organised in meeting the minimum of information. Each staff file would be more informative with a copy of job description, interview record to support the letter of appointment, and a suitable photograph of each staff member. Each member of staff is to be issued with a contract of employment. Two members of staff were spoken with, each being pleased and satisfied with the professional foundation offered to them through effective management. All staff have a statement of terms and conditions. Service users are supported and protected by these practises, and all new staff goes through an induction process that will ensure that they are going to be the right person for the home. The Care Manager is committed to a learning environment. She is due to complete the final stage of the RMA this year. Staff induction programmes are meaningful and well established, forming the base upon which in-service supervision and training are planned. Overall the evidence shows a satisfactory account of a training programme. It was advised that a personal training record be kept on file, that offers a full understanding of training needs. A majority of members of staff hold a valid certificate in first aid, and 75 have a NVQ level 2 or 3 qualification. Supervision is conducted by the Care Manager, which would be better maintained with delegated responsibilities, cascaded throughout the staff, to include all staff, on a two-monthly basis. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. The Registered Provider of the home accompanied the Care Manager and Inspector for the day. The inspector was impressed by the openness and confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Evidence was secured to confirm a quality monitoring system has been well maintained, based upon audit of standards, care plans and feed back from service users and relatives. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 24 EVIDENCE: The Care Manager has demonstrated competence in establishing a solid policy portfolio that has been implemented, to achieve a high standard of set aims and objectives. An experienced senior carer with a professional portfolio of practical and managerial experience, ably supported by a well qualified, experienced carers, whom represent an effective care management team Staff meetings are held regularly in which staff are encouraged to participate fully in the management and direction within the home. The inspector observed at first hand the confident interrelationship that exist, not only between management and staff, but also between staff and residents. Evidence was secured to acknowledge achievements, ongoing and planned objectives. Involved within this process are the views of service users and relatives, confirmed at case tracking and informal discussion. Social Workers’ review meetings are often a vehicle for assessing quality. Staff meetings are held monthly. There was strong evidence of openness and honesty in speaking with service users, relatives and staff, in which day to day events and episodes are freely discussed. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. Standards are discussed at staff meetings, daily reports, direct observation involvement and one to one staff meetings. The Provider was asked to prepare a development plan for 2008/09 to encompass the planned extension. The Care Manager was advised to prepare an inventory of risk for all areas of the Home, to meet the ongoing standards for fire protection, and to establish a firm foundation for development planning. The procedures manual was randomly examined, and found to offer a very comprehensive reference. COSHH, Infection control and managing dementia procedures were examined and found to be informative and up to date. All procedures are dated, requiring upgrading. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions organised by a member of staff recognised as a fire safety officer. Policies have been reinforced in accordance of requirements made at the last fire inspection. Discussion with the Care Manager indicated that supervision sessions and individual training programmes are areas that with continuing improvements, will enhance the desired impact on quality of service. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 25 and comfortable environment for elderly service users. This was confirmed by inspection of service agreements for gas supply, hoist maintenance, PAT and water supply. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. A two monthly audit needs to be established. No serious accidents have been recently reported. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 2 3 Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? None 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. 1 2 3 4 5 6 7 Refer to Standard OP27 OP33 OP19 OP36 OP29 OP30 OP24 Good Practice Recommendations That staff levels are maintained to appropriate levels Provide a development plan for 2007/08/09 All service area doors to be secured when not in use, and stores to be safely organised. Supervision of all staff is to be formally documented six times a year. The registered person must demonstrate robust recruitment procedures within the home. A training matrix was recommended to easily identify individual team member training needs. That a stair gate be installed DS0000066241.V343883.R02.S.doc Version 5.2 Page 28 Marlyn House 8 OP9 Secure a suitable CDA register, ensure that creams and ointments are recorded on MAR sheets. That a front sheet on each MAR identify residents. That a list of suitably qualified carers is attached to the MAR file. That bedroom windows conform to standard. That each resident has a contract clearly indicating the agreed bedroom identifier. That toilets are provided with engaged signs. 9 10 11 OP38 OP2 OP10 Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marlyn House DS0000066241.V343883.R02.S.doc Version 5.2 Page 30 - 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. 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