Inspection on 14/08/07 for Marriott House and Lodge

This inspection was carried out on 14th 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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Marriott House / Lodge Tollhouse Close Chichester West Sussex PO19 1SG Lead Inspector Ms A Campbell-Currie Key Unannounced Inspection 10:00 14 and 15th August 2007 th 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 Marriott House / Lodge DS0000069309.V342808.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. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marriott House / Lodge Address Tollhouse Close Chichester West Sussex PO19 1SG 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) 01243 536652 01243 783006 sandy.owens@barchester.com Barchester Healthcare Homes Ltd Mrs Sandra Kay Owens Care Home 119 Category(ies) of Old age, not falling within any other category registration, with number (119), Physical disability (119), Physical of places disability over 65 years of age (119) Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 72 service users who require nursing care may be accommodated of whom up to 15 may be in category PD. Only service users in the PD category over 50 years of age may be admitted. N/A Date of last inspection Brief Description of the Service: Marriott House and Lodge is a care home registered for nursing care. The registration is for older people and the home can accommodate up to one hundred and nineteen service users. It is a large property that has been arranged into two houses. Marriott Lodge is the smaller of the two houses and is solely used as a residential unit for up to forty-seven older people. This home is arranged on three floors and has a lift between floors. Accommodation is provided in single and double bedrooms. There are several lounges and a large communal dining area. Marriott House provides accommodation for up to seventy-two service users who need residential or nursing care. This building is arranged on three floors and has a lift between floors. Accommodation is provided in single and double bedrooms some of which have en-suite facilities. Communal areas include lounges and a large dining room. There is a shared garden between the two houses, which is pleasant and well cared for. The property is situated in the centre of Chichester close to the shops and the railway station. Fees range from £331 to £1000 per week. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection took place over two half days. It was the first inspection since the service was registered under a new company name in February 2007. The registered manager was on leave so the deputy manager assisted with the inspection and provided all the help and information needed. There were forty-four people living in Marriott House and nineteen living at Marriott Lodge. Judgements have been made from information gathered before the inspection and during the site visit. The manager completed an Annual Quality Assurance Assessment (AQAA) form that provided a great deal of useful information about the way the home is run and the further improvements that are planned. Twenty-six people living in the home were sent surveys to find out their views and nine were returned. Seven surveys were sent to relatives and two were returned. A partial tour of Marriott House and the communal areas of The Lodge was carried out. There was a discussion with eight people living in the home, one relative and a visitor and nine members of staff including the activities coordinator and administrators. Relevant documents and case files were read including Regulation 37 incident forms that had been sent to the Commission. The manager has confirmed that The Lodge is to be closed for refurbishment in September and there is a plan for most of the nineteen people living there to move to Marriott House; three people will be moving to a local home run by the same company. Relatives and other people involved in supporting people who live in the home have been consulted. The move is due to begin on 27th August; for this reason less time was spent in The Lodge. The outcomes for service users have been assessed in relation to twenty-eight of the thirty-eight National Minimum Standards for the care of older people; including those that are considered to be key to the welfare of service users. Four requirements have been made following the inspection. What the service does well: The enthusiasm and commitment of the staff spoken with was impressive. People said they enjoy their work and want to provide the best experience for people who live in the home. The staff spoken with feel well supported and said they work well together as a team. They said that they are encouraged to attend training that would help them in their work. There is an open atmosphere in the home and everyone spoken with said that the manager and senior staff are supportive and available. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 6 Comments from other people included: “the staff are wonderful, they couldn’t do more for me”, “some are excellent”, “the manager is always available to deal with any problems or queries”, “I am very happy with the care my mother receives and it has given me a different opinion of ‘the care home’ “, “staff always listen, they are kind and compassionate even when they are very busy” and “the staff seem very happy and well looked after”. The assessments and care plans that were seen were very detailed and up to date; staff said they had the information that is necessary to provide the care that people need. The deputy manager and other staff said that there is a good relationship with health and social care professionals to make sure that people get the extra help that they need. There was evidence of this on case files. The home is committed to helping people maintain and develop their independence; two people said that everything is being done to help them to get around independently and one person was at a rehabilitation centre for part of the day. People are encouraged to maintain contact with relatives, friends and community activities; important contacts were noted in the care plans. One person who returned a survey said: “relatives are always welcome”, and people visiting the home also said this was the case. There are lively and interesting activities during the week with posters and photographs displayed and available. The dining room is attractively set out in restaurant style and there is a good variety and choice of meals. The refurbishment programme in Marriott House means that the home is well furnished with good quality shower and bathroom facilities. What has improved since the last inspection? What they could do better: The manager and staff team should make sure that people temporarily moving from The Lodge to Marriott House are fully involved and are able to make choices about their rooms to help them settle in. The home should find ways to show that people living in the home and their relatives are fully involved in their assessments, care planning and reviews. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 7 It is recommended that weekend staff cover should be reviewed to ensure that people are able to take part in activities of their choice. The manager should ensure that all the required paperwork regarding staff recruitment is kept on file to show that recruitment is thorough for the protection of service users. A requirement has been made with regard to this matter. The manager should make sure that all staff have an annual appraisal and recorded supervision meetings at least six times a year. A requirement has been made with regard to this matter. All staff should attend fire training as required to make sure that they know how to protect people in the event of a fire. A requirement has been with regard to this matter. The manager should make sure that people are protected from the risk of fire if they wish to have their bedroom doors open. A requirement has been made with regard to this matter. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Marriott House / Lodge DS0000069309.V342808.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 Marriott House / Lodge DS0000069309.V342808.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. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information that they need to help them to make a choice about moving to the home. People are provided with a contract of the terms and conditions of their stay. Thorough assessments of peoples needs are carried out before a decision is made about whether or not the home could meet their needs. People are encouraged to visit the home before they make a decision about moving. The home does not provide Intermediate Care. EVIDENCE: There is a Statement of Purpose, Service User Guide and a brochure to assist people to make a choice about moving to Marriott House or The Lodge; there are copies in service users’ rooms. Two of the people spoken with said that their relatives had assisted them in choosing the home and had all the Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 10 information that they needed. People are provided with the information that they need in order to make a decision about moving to the home. Contracts are provided that outline the terms and conditions of the person’s stay. Samples of contracts for people placed by social services departments and those who pay their fees privately were seen. Service users sign to say that they have received the contract and they are then given a copy. Two people who returned surveys were not clear that they had received a copy of their contract. There is a new format available for carrying out a comprehensive assessment of the person’s needs before they move to the home. The manager said that either she or a senior member of staff qualified to carry out assessments visit the prospective service user at home or in hospital. A decision is then made about whether or not the home could meet the person’s needs. The deputy manager gave two examples where people had not been accepted to the home because the manager felt that their needs could not be catered for. A sample of six case files were seen and showed that assessments had been carried out before the person moved in. A further assessment was carried out on admission; this assessment included details of the person’s health and medication requirements. Any cultural issues, special needs or allergies are noted on the initial assessment. People’s spiritual needs and wishes at the end of their life were also documented. There was no indication on the paperwork to show that the person themselves had been involved in the assessment. There was evidence to show that assessments carried out by other health and social care professionals had been taken into account. There is a policy regarding encouraging people to visit the home before a final decision to move is made; one person explained that she had spent a week in the home before she moved. The deputy manager said that a number of people have regular respite in the home before making a decision about a permanent stay at the home. One person said she had moved from a different care home and that she much preferred this one. Intermediate care in not provided at Marriott House or The lodge. Marriott House / Lodge DS0000069309.V342808.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs are set out in an individual plan of care to ensure that people’s needs are fully understood and met. People are protected by the home’s policies and procedures for dealing with medication. People feel they are treated with respect and their right to privacy upheld. People can be assured that at the time of their death they will be treated with care, sensitivity and respect. EVIDENCE: There is a care planning and review process in place. Feedback from the surveys and in discussion with service users indicated that on the whole staff understand their needs. Samples of care plans were read; the information was detailed and included all aspects of the person’s needs. Health care needs were clearly identified with guidance provided to staff. Care plans included religious requirements where appropriate and the person’s wishes after their Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 12 death. There was a full life history to ensure that people’s social and emotional needs would be understood and catered for. Service users and their relatives had been involved in this aspect of their care plan. Risk assessments had been carried out regarding skin integrity, mobility, moving and handling. People’s nutritional needs were identified and weight charts showed that people are weighed monthly. The care plans had been reviewed each month and some changes to the person’s needs were noted. Not all service users spoken with were clear that they had a care plan and there was nothing on the documentation to show that the person had been involved in the process. This issue was discussed with the deputy who said that people had been involved but that this had not been noted. The care staff spoken with said that they had the information that they needed in the care plans to guide them. It was evident from case files and discussion with service users that they are able to access their GP or health care professionals as required; there was an indication of involvement and guidance from a nutritionist and a community psychiatric nurse. Staff and service users confirmed that people are seen in the privacy of their rooms. The deputy said that the home encourage people to maintain and develop their independence. There were a number of examples observed during the day and three people in particular who were spoken with had been supported in maintaining their mobility. Physiotherapists are accessed by referral from the GP; some people pay for this service privately. Wound care was discussed with the deputy manager and examples of wound care management were seen. One person in the home has a pressure wound that is being managed appropriately. There are medication policies in place including a homely medicine policy that has been signed by the GP. The clinic rooms in both buildings have been fitted with air conditioning to keep them at the correct temperature. The deputy manager is responsible for ordering and checking medication coming into the home. The storage facilities and a sample of records in Marriott House were checked and found to be in order. There have been no drug errors recorded; the deputy manager said that had been a recent error made by the pharmacy that was noted before the medication was administered. One person in the home is supported to be self-medicating and a risk assessment had been carried out in June to ensure that the person was still able to administer her own medication safely. In Marriott House two nursing staff administer medication; the lunch-time medication round was observed. One nurse is responsible for ensuring that people on the ground and top floor have the medication they need at the time they need it. The second nurse is responsible for those on the ground and top floor. The deputy said that people who need their medication at a certain time are noted and the night staff give early medication before breakfast. There is an efficient system for ordering and returning medication to ensure that no errors occur. The storage and Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 13 recording of controlled drugs was seen to be in order. The medication in The Lodge is administered by staff who are suitably trained and experienced to do so. The importance of protecting the privacy and dignity of service users is included in the induction programme and newly appointed staff are given guidance on how to provide personal care. Care staff spoken with said that they had been given guidance about these issues when they started in post. The manager said that people can choose the gender of the care staff who provides their care, comments on a survey from a relative indicated that the gender mix of the staff team is good in order to facilitate personal choice. Staff were observed to be providing care in a way that protects privacy and dignity. On the whole call bells were responded to quickly and a safety issue was addressed swiftly to ensure that people were protected from harm; however one person said that she had waited a long time for a member of staff to attend when she had a fall. Service users and relatives praised the care staff and one person said that some are ‘excellent’, others said ‘they can’t do enough for me’, ‘the staff are very kind and helpful’. Two senior staff have attended training to improve their understanding of palliative care. There are policies in place to ensure that people would be well cared for at the time of their death. Marriott House / Lodge DS0000069309.V342808.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People find that the lifestyle experienced in the home matches their expectations and preferences. People are supported to maintain contact with family, friends and community activities. People are supported to make choices about their daily lives. A wholesome, appealing and balanced diet is provided and people take their meals in pleasing surroundings. EVIDENCE: There is a lively programme of activities in Marriott House; the weekly programme of activities is given to every service users; copies were seen in peoples rooms. Some people who are able to have the opportunity for outings to local places of interest including garden centres and other local places of interest. The minibus can accommodate five people and the activities coordinator said that the staff try to ensure that everyone who wants to, has an opportunity to go out. The service users spoken with said they could go out if they wish to; sometimes with their families. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 15 Peoples interests are noted in their care plans and they are able to express their views and wishes at resident meetings. Two people indicated that there are fewer activities at weekends because the activities coordinator does not work then. This was discussed with the deputy manager who said that this issue would be discussed with the manager. The activities coordinator has two people who assist her so that some people can have one–to-one activities as well as group sessions. The activities coordinator has attended courses to help her in her work and she said this opportunity had given her good ideas to put into practice. Two staff have attended hand and foot massage classes and this activity is popular with service users. During the two half days there were several small group activities during the afternoons and a number of people were involved; other people chose to sit quietly in a separate lounge or sit in their rooms. Service users have an activities care plan and records are kept of their involvement so that attendance can be kept under review. It was clear from discussion and case records that people are supported to maintain contact with family and friends. Relatives who returned surveys indicated that this is the case and that they are made to feel welcome in the home. People are encouraged to maintain their independence and to remain involved in community activities. There is a monthly tea dance that is open to people in the community. A local vicar is involved with the home and provides a monthly communion service for those who wish to take part. People’s spiritual needs were noted on their case files; the deputy manager said that there is no one staying in the home who does not practice the Christian faith at the moment but other spiritual needs could be catered for. A variety of cultural festivals are celebrated and recently a ‘cruise week’ was arranged when each day a different country was celebrated and dishes from the country served at meal times. The menus are displayed outside the dining room, which was tastefully laid out at lunch-time with a small flower arrangement on each table. People said that the food is good and they have a wide variety of meals to choose from. One person had commented that the supper menu is limited; however there is always a variety of snacks available and people are supported to choose what they wish to eat during the day or at the mealtime. The head chef said that he provides the evening meal as well as lunch. The deputy manager said that about ten people choose to have breakfast in the dining room and they could choose a cooked breakfast every day if they wish. Special diets are catered for and there is a list of people’s dietary needs in the kitchen. Some people who needed assistance to eat were taking their meal in the dining room. Soft meals were presented in an attractive manner however some people were then having the food mixed with no explanation Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 16 about what food they were eating. This was discussed with the deputy manager who said that staff are given guidance about the way people should be assisted at meal times. Peoples nutritional needs were noted on the case files that were seen and there was evidence to show that peoples weight is monitored monthly. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are confident that their complaints will be listened to and taken seriously. People are protected from abuse. EVIDENCE: There is a complaints policy that is given to people when they move to Marriott House and The Lodge. This can be provided in large print if necessary. There is a system for recording complaints that protects the confidentiality of individuals. Eight complaints had been recorded and responded to promptly and appropriately. Feedback from surveys and discussion with service users indicated that people know who to talk to if they have any concerns and they feel that their complaints would be listened to and acted upon. Residents meetings are held so that any concerns or issues can be discussed. A file is kept for letters and cards from people who were pleased with the service provided; eleven compliments have been received in the past twelve months. There are adult protection policies and training in place. The majority of staff have attended training and an update session was attended by some staff Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 18 during the inspection visit. Staff spoken with were clear about the need to report any concerns to the person in charge in order to protect service users. Two incidents of concern had been reported to the Commission and had been referred to the appropriate agency for investigation. There was evidence to show that mental health professionals have been involved in providing guidance for staff where behaviour difficulties have been noted. The deputy manager was advised to ensure that clear guidance about possible triggers for difficult behaviour and actions to be taken is provided on care plans for the protection of service users and staff. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable, well-furbished and well-maintained environment. Aspects of the home could present a potential risk to people living there. EVIDENCE: There has been a major refurbishment programme in Marriott House in the past twelve months and The Lodge is due to close in three weeks so that the building can be upgraded and refurbished. The home was clean and well furnished. The gardens are very well cared for and photographs and observation showed that the grounds are well used by service users and their families. Several shower rooms and bathrooms have been upgraded in Marriott House to provide better and safer facilities for people. There are two Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 20 maintenance staff and a gardener as well as a team of domestic staff employed to ensure people benefit from living in a comfortable home. The requirements made by the fire officer have been addressed. A number of bedroom doors did not have closures to ensure that if people like to have their doors open they would be protected in the event of fire. Some of the automatic door closures that had been fitted did not work because of the depth of the new carpets. At least two doors were propped open; this could present a risk in the event of a fire. A requirement has been made regarding this matter. The deputy manager was advised to seek the guidance of the Environmental Health Officer with regard to the window closures and the small windows on the first and second floors of Marriott House to ensure the safety of service users is protected. The sluice and laundry facilities are suitable for the size of the home. One person said that there is a problem with some clothing going missing. There were no complaints recorded about this matter. The information given to service users indicates that all clothing should be named; one member of staff said that she assists people in naming their clothes if they do not have family to help them. Marriott House / Lodge DS0000069309.V342808.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of the staff meet the needs of people living in the home. Service users are not fully supported and protected by the recruitment process and records. Staff are trained and competent to do their jobs. EVIDENCE: There were sufficient numbers of staff on duty at Marriott House at the time of the inspection to meet the needs of the people living in the home. The Lodge had nineteen people staying and only two members of staff on duty; this would not be sufficient in the event of an emergency. There are normally three people on duty and when the deputy manager was advised of the situation an additional member of staff was provided for The Lodge. The deputy manager was advised to ensure that staff understand that they need to call for additional staff at The Lodge if the need arises. A sample of staff rotas were seen and showed that there are two registered nurses on duty during the day and one at night in Marriott House. The manager and deputy manager are also available during the week. There are normally seven or eight carers in the mornings and five in the afternoons; an Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 22 additional member of staff comes in from six until eleven in the evening to provide twilight cover. There are four care staff on duty at night. The same number of care staff are on duty at weekends. There were comments from two relatives about the level of cover at weekends; this was discussed with the deputy manager. The staff spoken with clearly have a strong commitment to providing a good experience for people living in the home. They said that the team works well together and that they support each other so that people receive good care. A total of eighty-two staff are employed at the home. Twenty-six of the thirtynine care assistants have achieved the National Vocational Qualification (NVQ) level two or above and eight are working towards this qualification. Three staff have achieved the NVQ assessors award. There is a recruitment policy in place and the manager indicated that an equal opportunities approach is taken. There was evidence to show that this is the case. Samples of recruitment records were seen; these did not include evidence that interview records had been kept. The records seen did not include all the necessary documents; in two of the four files there was only one written reference. One person who had transferred from another home in the organisation did not have an application form or any references on file. A requirement has been made with regard to this issue. It was clear that the staff files are in the process of being reviewed and updated. There is a policy that no one begins work until at least a Protection of Vulnerable Adults (POVAfirst) check has been received and all the files seen included evidence that a Criminal Records Bureau (CRB) check had been received to ensure the protection of service users. There is a policy that CRB checks are renewed every three years to ensure that circumstances have not changed. There is a comprehensive induction and training programme. Staff said that they had been given the guidance they needed when they began work. A sample of training records were seen and it was clear that the systems and planning are in place to make sure that all staff will receive updated training in mandatory topics including health and safety, moving and handling, the protection of vulnerable adults and fire safety. It was not clear that all staff have attended the mandatory fire training, this could put service users at risk. A requirement has been made with regard to this matter. Staff are due to have annual appraisals which will identify their training needs. Staff said that they are encouraged to attend training in specialist areas that will assist them in their work, for example the care of people who have dementia. Staff said they are supported in their NVQ programmes. Registered nurses are supported to develop and update their nursing skills; there was evidence of attendance at specialist courses. Marriott House / Lodge DS0000069309.V342808.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, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run by a manager who is suitably qualified and experienced to do so. People benefit from the ethos, leadership and management she has provided. The quality assurance process does not fully show that peoples’ views about the home are taken into account. Peoples’ financial interests are safeguarded. The health, safety and welfare of service users is not fully promoted and protected. EVIDENCE: Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 24 The registered manager is well qualified and experienced to run the home. Sandra Owens is a Registered General Nurse; she is a specialist in the field of orthopaedics and has attended training in the care of people who have dementia. Mrs Owens has five years management experience and has achieved the Registered Manager’s Award. Recent courses attended include palliative care seminars and tissue viability lectures. It was evident from observation and feedback from service users and staff that the manager has created an open and inclusive atmosphere in the home. An open door policy is operated and all those spoken with said that the manager responds quickly to concerns, incidents and complaints. People living in the home were provided with a questionnaire in June 2006 to seek their feedback about the service. A number of people responded and the completed forms were available. The outcomes have been collated and published to show people that their views have been taken into account regarding how they felt about the home. There are opportunities through residents meetings and the key workers for people to express their views. There is no formal system to seek feedback from relatives or other health and social care professionals. Provider visits are carried out each month when an audit of all aspects of care is carried out. Service users are supported with their finances by relatives or solicitors if they are not able to manage their own affairs. The home has a policy of not being involved in supporting people with their finances; however one person does receive help and the local authority officer involved in the placement is aware of this. The records of transactions and receipts for this person were seen to be in order. There is an appraisal and supervision programme that has been introduced. All senior staff have had an appraisal and nursing and care staff are due to have them soon. All staff spoken with said that they feel well supported and that their line managers are approachable. Supervision records seen showed that people have had some supervision sessions but not all had received supervision at least six times a year. A requirement has been made with regard to this matter. There are systems, training and records in place to ensure the health and safety of service users and staff. Equipment is serviced as required. The requirements of the fire officer have been addressed. There were a number of bedroom doors that did not have safety catches so that they could be safely propped open and would close in the event of a fire; one person said that she usually has her door open. Some of the safety mechanisms on doors were not functioning and at least two doors were propped open. This could present a Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 25 risk to service users and staff in the event of a fire. A requirement has been made with regard to this matter. The deputy manager was advised to seek the advice of the Environmental Health Officer regarding the window catches and the small windows on the first and second floors. Not all staff have attended the required number of fire training sessions which may present a risk to themselves and service users. A requirement has been made with regard to this matter. Incident reports were seen and outcomes and actions were noted. The commission is kept informed of incidents in the home as required. Marriott House / Lodge DS0000069309.V342808.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 2 Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/a STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation Reg 17 (2) Reg 18 (2) Reg 23 (4) (d) Requirement Recruitment records must have all the required information to show that people are protected when new staff are employed. All staff should be provided with supervision as required to ensure they understand their role and responsibilities. All staff must attend mandatory fire training so that they know how to prevent risk of harm to service users in the event of a fire. Bedroom doors should have safety catches that work and meet the standard required by the fire service so that people would be protected in the event of a fire if they choose to have their door open. Timescale for action 30/09/07 2 OP36 31/10/07 3 OP38 30/09/07 4 OP38 Reg 13 (4) (c) 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 28 No. Refer to Standard Good Practice Recommendations Marriott House / Lodge DS0000069309.V342808.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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