Inspection on 29/12/04 for Marmion Nursing Home

Care Homes For Adults (18 ­ 65)Marmion Nursing HomeStretton Street Glascote Tamworth Staffordshire B77 2BHUnannounced Inspection29 November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Marmion Nursing Home Address Stretton Street, Glascote, Tamworth, Staffordshire, B77 2BH Email address Tel No: 01827 67953 Fax No: n/aName of registered provider(s)/company (if applicable) Grangemoor Care Homes Name of registered manager (if applicable) Steve Bridges Type of registration Care Home No. of places registered (if applicable) 24Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (24) Registration number E090000183 Date first registered 29 July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30 July 2002 yes NO 4/12/03 If Yes refer to Part CMarmion Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 329 November 2004 10:30 am Mrs Sue MullinID Code075190Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMarmion Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers Agreement Sue Mullin Darryl Davies 5 January 2005 Signature Sue Mullin Signature Signature Darryl DaviesLead Inspector Second Inspector Locality Manager Date Public reportsIt should be noted that all CSCI inspection reports are public documents.Marmion Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Marmion Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Marmion Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Marmion care home with nursing accommodates service users with mental health problems from the age of 18 years and over. The home caters for 24 service users in total. The home is built on two levels accessed by a passenger lift and has communal areas, two lounges and a dining room. There are three bathrooms, including a shower facility and five separate toilets throughout the home. Five single rooms have en suite facilities. The home is situated less than one mile from the centre of Tamworth and has a bus stop 400 yards away.Marmion Nursing HomePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection took place over one day by one inspection officer. The care manager was not present and the care home was in the charge of Staff Nurse Christopher Homer RMN along with two care staff. The home currently caters for 24 service users with one service user at the George Bryant Centre and one vacancy. 22 nursing residents in total in the building. The whole home was very lively, with Christmas decorations in abundance. Choice of Home (Standards 1-5) 3 of the 5 standards were met and 2 were not inspected on this occasion. The statement of purpose and service users guide were available within the home. Prospective service users and relatives are welcomed to view the home and meet others prior to making a decision about a placement in the home. Individual Needs and Choices (Standards 6-10) 3 of the 5 standards were met and 2 were not inspected on this occasion. Many of the client group have complex mental health needs and these are reviewed on a regular basis, any identified needs are met. Care planning entries are comprehensive and regularly reviewed. Lifestyle (Standards 11-17) 5 of the 7 standards were met and 1 was not inspected on this occasion. The service users spoken to confirmed that they were happy in the homes environment, they were encouraged to voice their opinions and have a say in the running of the daily regimes within the home. Personal Healthcare Support (Standards 18-21) 3 of the 4 standards were met and 1 was not inspected on this occasion. The medication is always administered under the guidance of qualified nurses. Healthcare needs are met where appropriate and NHS entitlements are accessed where required via the route of a GP referral. Concerns, Complaints and Protection (Standards 22-23) 2 of the 2 standards were met. There have been no complaints made via the Commission since the last inspection. Environment (Standards 24-30) 6 of the 7 inspected standards were met. Marmion Nursing Home Page 6 Following a brief tour of the home it was found to be clean and comfortable. Personal effects were found in bedrooms and service users spoken to were generally satisfied with their environment. New, good quality carpets have been laid throughout the ground floor and give an impressive welcome feel to the home. All bedrooms have a washbasin and there are sufficient bathroom facilities throughout the home and all toilets and bathrooms were lockable. Bedrooms of service users to not contain a lockable facility or a lock on the door. Some five service users have requested this facility which has been required in the last two inspection reports and now needs to be addressed as a matter of urgency. The inspector was informed that service users have complained of items going missing from their rooms. Staffing (Standards 31-36) 2 of the 6 standards were met and 2 were not inspected on this occasion. Staffing levels and skill mix were found to be sufficient and in line with minimum requirements. Management and Administration (Standards 37-43) 2 of the 7 standards were met and 4 were not inspected on this occasion. Fire tests were confirmed by the care manager as being undertaken on a weekly basis but not all day staff had received two fire drills, night staff four fire drills yearly. This must be rectified in line with the fire authorities regulations. Not all staff had received yearly manual handling training. This must also be rectified in line with the Health and Safety regulations. The inspector discussed the recording of hot water temperatures and it was determined that no record had been kept for two months or so. This needs to be rectified in line with Health and Safety Legislation. Service users appeared happy and content. Morale was high and service users input into the daily regimes was apparent.Marmion Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO) N/AMarmion Nursing HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action All service users should be provided with a 1 23(2)(e) YA26 · lock to their bedroom door and be provided with a key. (Subject to capabilities) a lockable facility in their rooms 29/01/05·The registered person must ensure that a · 2 23(2)(a)(b) YA42 · With record of hot water temperatures in immediate maintained and available for inspection effect when required. The luminaire at the top of the main stairwell is replaced/repaired 29/12/04323(4)(d)(e)YA42The registered person shall make arrangements for all staff to receive adequate fire drills every year. · Care staff must be supervised every two months and this should be recorded and available for inspection when required. Please ensure that staff views are taken into account by regular staff meetings, which are documented by trained staff and available for inspection when required.With immediate effect418(2)YA36·29/02/05Marmion Nursing HomePage 9 516 (2)(n)YA14Activity programmes displayed in the home should be accurate. The registered person must ensure all staff receive appropriate manual handling training every year. The registered person must ensure that NVQ training is ongoing in the home to meet 50 of staff who have achieved this by April 2005.with immediate effect 29/02/05618(1)(c)(i)YA42718(1)(c)(1)YA3229/02/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Marmion Nursing Home YES YES NO YES YES YES NO NO YES YES YES Page 10 Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES NO YES NO YES NO YES 11 1 X YES YES YES YES 10 9 29/11/04 10.30 5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Marmion Nursing HomePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are Key findings/Evidence Not assessed on this occasion x Standard met? 0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The care staff of the home confirmed that all service users are assessed prior to admission into the home. The home confirms it can meet the service users needs prior to being admitted. The records were examined and evidenced this.Marmion Nursing HomePage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The vast majority of the service users have complex mental disorders and require consultant referral from time and this is sought and clearly documented in the care plans. All the care staff in the home communicated freely, professionally and courteously to all service users in the home on the day of the inspection. Advocacy services are available on request. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Prospective service users and relatives are welcomed to view the home and meet others prior to making a decision about a placement in the home.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? Not assessed on this occasionMarmion Nursing HomePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Many of the client group have complex mental health needs and these are reviewed on a regular basis, any identified needs are met. Care planning entries are comprehensive and regularly reviewed. One service users care plan was examined in detail. This was comprehensive and evaluated regularly. The named nurse system is in operation and those files seen contained an adequate daily statement and external professional visits were documented. All described individuals current mental and physical conditions. The nurse in charge spent some time explaining in detail this service users history from admission some four weeks prior to the inspection and clearly understood her identified needs. The service users son was consulted on her care planning when he visited during the inspection and he was very satisfied with the progress made to date. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not assessed on this occasionMarmion Nursing HomePage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Staff spoken to spoke highly of the management team and their input into the day to day running of the nursing home. The client group are active and very busy and the staff encourage the service users to view their opinions and have a say in the daily routines, menus and so on.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? There was evidence that staff recognise that each service user has different needs and also different areas within every day life, which may pose a potential risk. There are many service users who smoke heavily in the home and two have been known to smoke in their bedrooms, which is against the homes rules and regulations. The inspector discussed this situation with care staff in the home and was pleased they could clearly identify the risks for those people and how the home manages those risks. There was good evidence of risk assessing taking place and evidence that these had been regularly updated. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not assessed on this occasionMarmion Nursing HomePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Several service users in the home were engaged in conversation with the inspector on the day of the inspection. However, due to their mental state it was difficult to ascertain whether their social and independent living skills were facilitated fully. The home have some service users with enduring mental health problems that can inhibit their ability and willingness to attend classes to promote and develop social skills. It was felt throughout the inspection that service users were treated with respect and empathy and for some service users the staff interpreted their needs which appeared to be accepted well. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Several service users were keen to talk to the inspector and explained that where possible their own circumstances with regard to their education and working life. One service users goes to a computer class, a cooking class and a floristry class at Tamworth college. One other goes to the Nuffield centre one day a week and this is a paid activity. Transport is arranged for this. Several service users walk to a local drop in centre on a Friday for bingo, knitting, jigsaws, art and craft lessons.Marmion Nursing HomePage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Not assessed on this occasionStandard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 2 Key findings/Evidence Standard met? Whilst the care staff ensure that the service users have in house parties and entertainment where possible, there is no dedicated activity staff employed. The activity programme displayed in the home was not accurate and very misleading. Several residents spoke about the lack of activities. Evidently , the Karaoke machine is now broken and has not yet been replaced. This appears to have been a good source of entertainment for the service users in the home on a regular basis. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? There are several service users who have formed relationships with each other but there are no couples presently sharing the same room. Advice and guidance are available as and when necessary. When service users are taken out by their families for days out this is recorded in their care plans. Currently there is no one on regular week end leave. Families are encouraged to be part of the care planning process with the service users consent. Following a conversation with staff it was evident that the home positively encourages visitors to the home to support the service users. The staff confirmed that visitors were welcome at any time and would always be offered hospitality. Service users can receive their visitors in private. The whole environment was found to be active and lively.Marmion Nursing HomePage 17 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The service users spoken to confirmed that they were happy in the homes environment, they were encouraged to voice their opinions and have a say in the running of the daily regimes within the home. Several service users were observed making their own choices at various times throughout the day, and it was evident from theirs and the staffs approach that this was the normal occurrence. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The above standard is met based on inspection of the menus and discussion of food choices with service users. Service users confirmed that there is always plenty of food on offer and that they are provided with a choice of food. Menus seen confirmed this. The inspector joined the service users in the dining room at lunchtime and sampled the food which was, faggots, potatoes and vegetables with a cheesecake to follow. Some service users had sandwiches or salad as an alternative. One service users helped with the clearing up and confirmed that this was his usual practice.Marmion Nursing HomePage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? It was very pleasing to see the staff attending to the service users in a caring, professional manner. All service users were called by their preferred name and treated with dignity and respect during the inspection.Marmion Nursing HomePage 19 Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) X03 Key findings/Evidence Standard met? Healthcare needs are met where appropriate and NHS entitlements are accessed where required via the route of a GP referral. All of the service users in the home at present were ambulant and no one was poorly or in bed feeling unwell. No one was receiving district-nursing services. Chiropody services are arranged six monthly. Dental treatment is organised when necessary. Currently there is are several GP surgerys visiting the home and attending to service users medical needs. Two consultant psychiatrists review all the service users regularly, one consultant undertakes a surgery on the last Friday of the month and this is working well. There are regular SW reviews undertaken for individuals in the home. There are no other services visiting the home at this present time.Marmion Nursing HomePage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The medication is always administered under the guidance of qualified nurses. The home use a local Chemist and prescriptions are ordered monthly and delivered by the Chemist; these take the form of bottle to patient. Delivery, stock and disposal records are maintained. The MAR sheets were examined and all found to be in order. Qualified staff administers all medication in line with NMC requirements. There are currently no self-medicated service users at present. When going on leave service users take their tablets in a container, outlying each days requirements separately. This is then checked when the service user returns to the home. There are no controlled drugs used in the home at this present time. Any medication needing to be kept cool was in a locked box in the fridge in the kitchen. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Marmion Nursing HomePage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3Key findings/Evidence Standard met? There is a robust complaints procedure on display in the home.The staff in the home state that there have been little grumbles voiced from service users which have been resolved immediately. No verbal complaints have been made to the home since the last inspection. The Commission have not received any formal complaints relating to this homeMarmion Nursing HomePage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? This procedure for handling monies is done in accordance with service users wishes and this is documented. The staff confirmed that over 60 of service users smoke cigarettes and much of their weekly allowance is spent on cigarettes. Staff, with the permission of the service users buy the cigarettes and hand them out at an agreed time each day to ensure that each individual does not run out. In the past when all the cigarettes have been smoked too soon, tension builds up in the home and some service users become agitated and upset. The procedures adopted in this home have avoided this situation. There have been no incidents of any form of abuse reportable to this Commission.Marmion Nursing HomePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? A brief tour was undertaken of the home and several bedrooms were seen to be personalised and pleasant. New carpets had been laid throughout the ground floor of the home. The communal areas were ample to meet the spatial requirements and there were sufficient toilets throughout the home. The gardens were well maintained and very pleasant and peaceful. All areas of the home were clean and tidy.Marmion Nursing HomePage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence The standard is met by direct observation. NO NO YES 14 5 5 0 Standard met? 3 14 00 0 5 0Marmion Nursing HomePage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? Bedrooms of service users to not contain a lockable facility or a lock on the door. Some service users have requested this facility which has been required in the last two inspection reports and this now needs to be addressed as a matter of urgency. The inspector was informed that some service users have complained of items going missing from their rooms. All service users should be provided with a · · lock to their bedroom door and be provided with a key. (Subject to capabilities) a lockable facility in their roomsStandard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? All bedrooms have a washbasin and there are sufficient bathroom facilities throughout the home and all toilets and bathrooms were lockable.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? Following a brief tour of the home it was found to be clean and comfortable. Personal effects were found in bedrooms and service users spoken to were generally satisfied with their environment.Marmion Nursing HomePage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? Following discussions with the staff it was determined that all machinery was in full working order throughout the home. There were no hoists in the building and no one currently requiring usage of one. There was no one poorly in bed during the visit or service users with pressure sores. There are a few commodes used at night for service users convenience. All service users are ambulant. The provision of aids and adaptations follows assessment by suitably qualified persons, where necessary. The nurse call system is fully operation in all service users areas and this was confirmed by the care staff.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? Infection control measures were in place throughout the home. The home have comprehensive policies and procedures in place. There were no malodours detected within the home. All waste was disposed of correctly and there were sufficient hand washing facilities available throughout the home. Waste bins were prominent and the laundry area clean and tidy. All machinery in the laundry was in full working order. Service users are encouraged to undertake their own washing under supervision where possible.Marmion Nursing HomePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? This standard was met based on discussion with care staff and management at the home. All staff have a clearly defined job description. Staff on duty were aware of good practice in relation to service users with enduring mental health problems. This was endorsed by direct observation of their practices throughout the inspection. Staff work together as an efficient team and understand their own and others roles towards a teamwork approach to the provision of care. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 1 Key findings/Evidence Standard met? General discussion with the staff on the day of the inspection, revealed an understanding of the needs of the service users and of the ethos of the home. There was evidence that the staff group liaised with and had an understanding of the multi disciplinary support available for service users. However, information provided by the staff in regard to the lack of NVQ training was disappointing to the inspector. Two members of care staff confirmed that they were patiently awaiting funding to commence this training. However, despite two attempts over the last year to arrange funding this has come to a standstill. There are 10 care staff and none hold an NVQ Level 2 certificate in direct care. The home must have 50 of their care staff trained to this level by April 2005. Arrangements must be made to facilitate this training.Marmion Nursing HomePage 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 8 14 0 X 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X093 Key findings/Evidence Standard met? As this is a care home with nursing registered prior to April 1st 2002 agreed staffing levels are maintained. There is always a qualified nurse on duty over a twenty-four hour period. Additionally there are: Early shift = 7.30 ­ 2.30 pm with two care assistants Late shift = 2.30 ­ 9.30 pm with two care assistants Night shift = 9.30 ­ 7.30 am with one care assistant There is also another carer five days a week who helps out from 7.30am ­ 10.00am. Staffing levels are based on the dependency levels of the service users in their care. Very little agency is used and there is a good supply of bank staff and staff willing to undertake extra shifts. Kitchen and domestic staff are adequate and care staff do the laundry. Maintenance/gardener as required Administrative work is undertaken by the owners No staff are employed under the age of 18 years. This standard is satisfactorily met. Marmion Nursing Home Page 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this time.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Manual handling training and fire drills for all staff were not up to date ­ this has been detailed further under standard 42.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met?2Care staff spoken to stated that they have not been supervised every two months. It was noted that care staff supervision was underway but did not contain two monthly reports. These supervision sessions must be completed regularly and they should be recorded and available for inspection when required. Staff meetings were irregular and a little haphazard. Please ensure that staff views are taken into account by regular staff meetings, which are documented by trained staff and available for inspection when required.Marmion Nursing HomePage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence Not assessed. X 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not assessed.Marmion Nursing HomePage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Not assessed on this occasion.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? This standard is met by direct observation at the last inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? Service users records, care planning files are all kept in a locked office in line with the Data Protection Act 1998. All records seen on the inspection were in good order, medicine records were accurate and fully completed. This standard is fully met.Marmion Nursing HomePage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 1 Key findings/Evidence Standard met? The luminaire at the top of the main stairwell is replaced/repaired Fire tests were confirmed by the care manager as being undertaken on a weekly basis but not all day staff had received two fire drills, night staff four fire drills yearly. This must be rectified in line with the fire authorities regulations. Not all staff had received yearly manual handling training. This must also be rectified in line with the Health and Safety regulations. The inspector discussed the recording of hot water temperatures and it was determined that no record had been kept for two months or so. This needs to be rectified in line with Health and Safety Legislation. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not assessed on this occasion.Marmion Nursing HomePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceMarmion Nursing HomePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 25 August 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Action taken by the CSCI in response to provider comments: Marmion Nursing Home Page 35 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 4 January 2005 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Marmion Nursing HomePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Marmion Nursing HomePage 37 Marmion Nursing Home / 29 November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000022350.V161283.R01© This report may only be used in its entirety. 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