Inspection on 16/05/06 for Marshview

This inspection was carried out on 16th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Marshview 06/06/07

Marshview 19/09/05

Marshview 22/04/05

Marshview 30/09/04

Marshview 20/04/04

Similar services:

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

The Shelley

Springfield House

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

CARE HOMES FOR OLDER PEOPLE Marshview 77 Marshfoot Lane Hailsham East Sussex BN27 2RB Lead Inspector Nigel Thompson Unannounced Inspection 16th May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marshview Address 77 Marshfoot Lane Hailsham East Sussex BN27 2RB 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) 01323 849207 01323 849207 Mrs Maria Mapletoft Mrs Maria Mapletoft Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is seventeen (17). Service users must be older people aged sixty-five (65) years or over on admission. That one named service user can be accommodated with a Dementia type illness. 19th September 2005 Date of last inspection Brief Description of the Service: Marshview is a large detached two-storey house situated in the market town of Hailsham. It is registered to provide care and accommodation for up to 17 older people. There are three double rooms, of which one has en-suite facilities and eleven single rooms. Nursing care is not provided. The home is situated in a country lane that is within walking distance of local shops and amenities. There are well maintained rear gardens and car parking facilities at the front of the property. All parts of the home are accessible via a stair lift and portable ramps give access to the front of the home and the rear gardens. Grab rails and toilet riser seats are installed throughout the home. There are three assisted baths and all bedrooms have a hand washbasin. None of the rooms have full en-suite facilities but there are sufficient toilet and bathing facilities to meet service users needs. Information about the service, including the Statement of Purpose, Resident’s Handbook (Service User’s Guide) and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The range of weekly fees, as of 16 May 2006, is £337- £480. Additional charges, not included in the fees, include hairdressing, chiropody, newspapers and transport. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven and a half hours in May 2006. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were fifteen service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the proprietor, who is also the registered manager. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. Five service users, one relative, two members of care staff, the cook and a visiting hairdresser were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: What has improved since the last inspection? Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 6 Pre-admission and care planning documentation has been reviewed, as required since the previous inspection, however there is still room for further improvement in this area. Risk assessments are now carried out to enable service users, within a management framework, to safely undertake risks in their daily lives. All complaints are now recorded as part of an improved quality assurance system. To ensure the protection of service users, recruitment practices have been reviewed and improved. In addition to satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures, staff must now provide a full employment history and two references prior to appointment. Staffing levels and dedicated management hours have been also been reviewed, as required, to enable the manager to more efficiently manage her time and more effectively fulfil her management duties. Systems for more effective communication, including service users’ reviews, meeting and satisfaction surveys have been developed and implemented to ensure residents are regularly consulted in how their individual care is delivered and more generally how the home is run. Requirements relating to health and safety have generally been addressed, to ensure the safety and welfare of service users. What they could do better: Pre-admission assessments should be completed in full and in consultation with the service user or a representative, to ensure that an individual’s care and support needs have been identified before moving into the home. It is important that service users’ care plans set out in detail the action which needs to be taken by care staff, to ensure that all individual health, personal and social care needs are met in a structured and consistent manner. It is also essential that care plans are regularly reviewed and updated, to accurately reflect the service user’s current and changing needs. Service users should be consulted regarding their social and leisure interests and an activities programme be implemented to reflect those interests and preferences. Staffing levels should be kept under review, to ensure that service users needs continue to be met. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 7 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. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 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 Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The pre-admission assessment must be completed in full to ensure that service users are admitted only when their care and support needs have been fully assessed by people competent to do so. Prospective service users have the opportunity to visit the home and know that it is able to meet their individual care and support needs. EVIDENCE: Since the previous inspection, as required, the Statement of Purpose and the Service User Guide, (Resident’s guide to Marshview) have been reviewed and improved and are both now comprehensive and informative. Concise information about the home is also made available to prospective service users in a brochure. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 10 The recording format for the pre-admission assessment has also been improved. However, in service users’ care plans that were examined, it was noted that certain sections had not been fully completed and consequently important information was not recorded, particularly in respect of social care needs and leisure and recreational interests. The manager confirmed that prospective service users are invited to visit the home to look around and meet with staff and existing residents. They often stay for lunch and are able to ‘generally get a feel for the place’. It was noted that the service users’ Contract/Terms and conditions of residence has been reviewed, as required, since the last inspection. There was evidence, in the cases of service users recently admitted to the home, that contracts had been issued to and signed by the individual themselves or a relative or representative on their behalf. Service users and relatives, spoken with during the inspection, were able to confirm that the home met their individual needs and aspirations: ‘The staff here are all very kind. They can’t do enough for you. I’ve no complaints’. ‘I can’t fault the place. Everyone is so kind and helpful’. The manager confirmed that intermediate care is not provided at Marshview and emergency or unplanned admissions are avoided. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Care plans lack sufficient detail to enable staff to meet service users’ assessed needs in a structured and consistent manner and do not always reflect their current or changing support needs. The systems for service user consultation and participation are good and service users are encouraged to make decisions about their day-to-day living. EVIDENCE: The registered manager has clearly worked hard since the previous inspection to ensure that service users’ assessed health, personal and social care needs are being met. Individual care plans that were examined show areas of significant improvement since the last inspection. Of particular note is the comprehensive front page ‘Resident’s Profile’ and the impressive ‘Dependency Assessment’, which provides at a glance details of an individual’s changing level of need/dependency in various key areas, including communication, mobility and personal hygiene. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 12 However, despite this improved recording system, the information gathered is evidently not always being used effectively for the benefit of the service user. In one case where a service user had been assessed as being at ‘High Risk’ on the Waterlow pressure sore report, it was noted that there was no further reference to this in any other section of the care plan, including the guidance for staff. Overall there is still insufficient detail regarding action to be taken by staff, to meet the assessed needs of service users and to ensure consistency of approach. There is however evidence of service users or their relatives being more involved, as required, in developing or reviewing individual care plans. A relative, spoken with during the inspection, confirmed this situation: ‘I don’t have any concerns about the care he receives. I have been shown my father’s care plan and have signed it to say that I am happy with it’. It was noted in several care plans that were examined that there was no record of an individual’s medication details having been recorded and weight charts had not routinely been completed. Satisfactory policies and procedures are in place for the control and safe storage of medicines within the home. Documentation, including Medication Administration Records (MAR Sheets) were found to be up to date and well maintained. The manager confirmed that all staff involved in administering medicines receive appropriate training. This was supported by documentary evidence and through discussions with care staff. All service users are registered with local GPs and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in individual care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. As part of their induction programme, the manager confirmed that all staff receive instruction on the principles of dignity and respect. This was evident through discussion, during the inspection, and from direct observation of staff interacting sensitively and professionally with service users. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users maintain contact with family and friends as they wish and benefit from a weekly activities programme and from good quality menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: Since the previous inspection, as required, a weekly activities chart has been developed and implemented. The manager confirmed that as there is no specialist ‘Activities Coordinator’ employed at Marshview, care staff are currently responsible for arranging and supervising activities, around their other duties and there is consequently ‘always some flexibility in the programme’. Recent outings have been arranged to local garden centres and tearooms and regular visitors to the home provide service users with various musical entertainment, ranging from light opera to ‘karaoke hymn singing’. Comments regarding activities from service users were generally positive but reflected an evident lack of structure: Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 14 ‘There’s often something going on but we don’t always know what until it happens’. ‘I take part in what I can’. The manager confirmed that visiting in the home is unrestricted – ‘as long as the service user wishes’ and service users are able to see friends or relatives in the lounge or in the privacy of their own room. A relative, spoken to during the inspection, was able to support this: ‘I’m always made welcome here. Everyone is so kind and helpful ’. The manager confirmed that wherever possible, service users are enabled and supported to make choices and take decisions affecting their life and daily routines, including menu planning. This was supported through discussions with the cook and service users, who confirmed: ‘There is a choice offered’. ‘I go round and see everyone each morning to discuss the lunch menu and what they would like to eat. As you can see, there is always a choice’. Service users are provided with a varied, wholesome and nutritious diet. At lunchtime a choice of main meal is available and special diets are catered for. As part of a four week rolling menu, a daily menu is displayed in the entrance to the dining area, reflecting service users’ preferences and including seasonal variations. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The open and inclusive atmosphere within the home enables service users, staff and visitors to express any concerns, confident that they will be listened to and acted upon. Service users are safeguarded from abuse through relevant staff training and robust policies and procedures. EVIDENCE: A clear and accessible complaints procedure is now in place, in the entrance hall. According to the manager, three complaints have been received by the home since the previous inspection, all of which had evidently been responded to appropriately to the satisfaction of the complainant. This was supported through examination of the complaints log. Service users, members of staff and a relative spoken to during the inspection, confirmed that they would have no hesitation speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to: ‘If I have a problem with anything, I only have to mention it and it is sorted’. Following discussion with the manager, the complaints procedure is to be reviewed and amended to include details of timescales. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 16 Since the previous inspection, two members of staff have attended a workshop, entitled ‘Training for the trainers’, on the subject of Adult protection and abuse. This course was arranged through East Sussex Social Services and enables the participants to cascade information to other members of staff within the home. The manager added that two ‘in-house’ sessions have been arranged for later this month and all staff will be expected to attend. This was evidenced by diary entries and confirmed by members of staff. Comprehensive policies and procedures relating to abuse and including whistle blowing are in place, however following discussion with the manager, it is recommended that they be reviewed and updated. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from accommodation that is safe, comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: It is evident from my ‘guided tour’ of the premises that there has been little change in the physical environment at Marshview since the previous inspection and standards remain generally high throughout. The well maintained décor, furniture and furnishings continues to provide a comfortable, pleasant and homely environment for service users. Service users rooms were found to be clean, comfortable and generally well maintained. However, it was noted that some rooms appeared stark, with bare walls and minimal furniture. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 18 As discussed with the manager, service users would benefit from more personalised surroundings, with pictures, family photographs and other small items of furniture and personal belongings, to reflect their individual taste, choice and interests. Sufficient toilet and assisted bathing facilities are provided throughout the home. All service users’ bedrooms have toilet and hand basin facilities. Since the previous inspection, as required, locks on communal bathrooms and toilets doors have been adapted, to enable staff to enter in the event of an emergency. Several rusty commodes have also been replaced. Infection control procedures are in place and clearly adhered to and levels of cleanliness remain high throughout. This was confirmed by comments from service users: ‘The home is always very clean’. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There are sufficient trained and competent staff on duty at all times to meet the assessed needs of the service users. Robust recruitment procedures and appropriate staff training ensures the safety and protection of service users. EVIDENCE: The manager confirmed that staffing levels within the home are sufficient to meet the current care needs of service users and there is always some flexibility for additional staff hours should the need arise. The staff rota indicated that there is a minimum of two care staff on duty throughout the day and one waking night staff. Cooks and domestic staff are also employed in the home. The manager continues to cover for staff sickness and holidays and is often directly involved in care provision. When not actually on the premises, she is on call. Service users and members of staff, spoken with during the inspection, confirmed that staffing levels at Marshview are adequate: ‘There’s always someone around and they are all so kind’. ‘It does get busy at times but we manage. If we are struggling or need more help, we only have to ask’. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 20 Recruitment policies and procedures are satisfactory, having been reviewed and improved, as required, since the previous inspection. Personal files relating to three recently appointed members of staff, examined during the inspection, were found to be generally well maintained, containing necessary information, including employment history, two references and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. The manager stated that appropriate induction, foundation and core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed by staff and supported by training records examined. There are currently five care staff who hold the National Vocational Qualification (NVQ) level 2. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from effective management, appropriately supervised staff and improved quality assurance systems. Satisfactory health and safety policies and procedures, within the home, help to ensure the protection of service users and staff. EVIDENCE: The atmosphere in the home remains relaxed, friendly and welcoming. Staff, spoken to during the inspection felt valued and supported by the manager and confirmed her open and approachable style of leadership and clear and positive sense of direction. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 22 The Registered Manager / Proprietor is suitably qualified and experienced to run the home. She is keenly aware of the need for more effective time management and since the previous inspection, as required, she has reviewed her specific management hours. The manager continues to provide all care staff with formal supervision on a regular basis and through discussions with members of staff, it is evident that she also operates an ‘open door’ policy, with staff able to discuss any issues at anytime. Staff spoken to confirmed the support and training they receive and acknowledged the personal benefit of effective supervision: ‘There’s no shortage of training here – whatever you want to do’. ‘Supervision is good. I find it very useful and the manger is always very supportive’. The home’s quality monitoring system includes satisfaction questionnaires for both service users and their relatives. The manager confirmed that, since the last inspection, recent surveys have been sent out although as yet no responses have been received. Following discussion with the manager, the current lengthy format for the survey is to be reviewed and amended to be more concise and provide space for any additional comments. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 23 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1a-c) (2a&b) Requirement It is required that the preadmission needs assessment be completed in full and in consultation with the service user or a representative. It is required that service users’ care plans set out in detail the action which needs to be taken by care staff, to ensure that all individual health, personal and social care needs are met in a structured and consistent manner. (Timescale of 19/12/05 not met). It is required that care plans be regularly reviewed and updated to accurately reflect service users current and changing needs. (Timescale of 19/12/05 not met). It is required that documentary evidence be provided regarding the management of incontinence and possible tissue breakdown. (Timescale of 19/12/05 not met) It is required that service users be consulted regarding their social and leisure interests and an activities programme be DS0000021161.V288512.R01.S.doc Timescale for action 31/07/06 2. OP7 15 (1) 31/07/06 3. OP7 2 (b & c) 31/07/06 4. OP8 12 (1), 13 (1) & 17 (1a) 16 (2) (m & n) 31/07/06 5. OP12 31/07/06 Marshview Version 5.1 Page 25 implemented to reflect those interests and preferences. (Timescale of 19/12/05 not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP27 Good Practice Recommendations It is recommended that staffing levels be kept under review to ensure that service users needs are met. Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marshview DS0000021161.V288512.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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