Inspection on 08/10/07 for Marston Court

This inspection was carried out on 8th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Marston Court 08/05/06

Marston Court 24/01/06

Marston Court 24/08/05

Marston Court 28/02/05

Marston Court 19/08/04

Marston Court 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Marston Court Marston Road Oxford Oxfordshire OX1 1ND Lead Inspector Jane Handscombe Unannounced Inspection 8th October 2007 11:10 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 Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marston Court Address Marston Road Oxford Oxfordshire OX1 1ND 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) 01865 241526 01865 722290 manager.marstoncourt@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust Mrs Theresa Jean Whitford Care Home 39 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (20), Learning disability over 65 years of age (3), Old age, not falling within any other category (39), Physical disability over 65 years of age (20) Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 39. 8th May 2006 Date of last inspection Brief Description of the Service: Marston Court is a care home providing personal care and accommodation for 39 older people and Day care facilities for 10 from the local community. The care home is managed by The Orders of St John Care Trust who are responsible for many care homes throughout the county of Oxfordshire. Marston Court is located in a residential area of Oxford approximately a mile from the city centre. Local shops, churches, pubs and other amenities are accessible to service users. Marston Court is a two storey building served by a lift. All rooms are single with shared bathroom facilities. The care home is divided into four wings, each having a lounge and dining area. The grounds are shared with the county office of The Orders of St John Care Trust providing some lawn and a secluded patio area with a water feature. Prices range from £495.00 - £680.00 per week. Items not covered within the fees include hairdressing, podiatry, newspapers and magazines, toiletries and contributions to some outings and activities. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’ which was undertaken on 8th October 2007. The inspection involved one inspector and took place over seven hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the registered provider, and any information that the CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service, staff members and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Five questionnaires were received from users of the service, six from relatives, carers & advocates, four from staff and one from health professionals. The inspector looked at how well the service was meeting the standards set by the government and has, in this report ,made judgements about the standard of the service. Comments received from residents during the inspection process included: “The staff are good, I have nothing to grumble about” “I can go to bed when I wish” “I am very happy here” Comments from relatives, carers and advocates include: “A complete all round service with staff of a very high standard” “Overall my family and I are very pleased with how mum has settled into a somewhat different environment and she seems overall a much more happier individual, whose mobility has improved as has her sense of safety and security…..mum enjoys an excellent relationship with a lot of the staff and we have seen a huge difference in her. Moving to Marston Court has been absolutely the right decision” “there is a lovely atmosphere – you feel welcome as soon as you enter. It is always clean and fresh” Comments from staff include: “The manager is very approachable and supportive” Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 6 “We get lots of training and I’m in the middle of doing my NVQ2” The inspector would like to thank the residents, their families, staff members and other health professionals for their time and assistance during this inspection. What the service does well: What has improved since the last inspection? Since the last inspection undertaken in May 2006, a full time activities coordinator has been employed and there is now a varied programme of daily activities provided for those who wish to partake, which takes into account their likes, dislikes and capabilities. Service users are now enabled to access to an interpretor where english isn’t their first language, details of which are readily available and displayed on the noticeboards within the home. The home are in the process of transferring all service users details into an improved care plan format, which when completed, should enable a more person centred plan of care which focuses on the individual’s wishes and preferences, and improve the accessibility of information to care staff. Staff members mandatory refresher training has been attended to and up to date. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area is excellent. All prospective service users are provided with detailed information about the home and the facilities they are able to offer and undergo an assessment of need prior to moving into the home to ensure that both parties are confident that their needs can be met appropriately. The home does not provide for intermediate care This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided to the Commission prior to the inspection and files viewed during the inspection process indicated that all prospective service users are provided with a pre-admission assessment to ensure that both the manager of the home and the prospective service user are satisfied that their needs can be met appropriately before being offered a permanent place. Additional information is sought from GPs, district nurses, hospital staff, social Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 10 workers, relatives and any other relevant person who could contribute to such an assessment. The prospective resident and/or their next of kin are invited to visit the home prior to making a decision, and are provided with a copy of the home’s Residents’ Guide which includes comprehensive information about the qualifications and experience of the manager and the staff team, the services that are provided at the home, a summary of the homes statement of purpose, details on how to make a complaint, important contact numbers and identifies the member of staff who will be their key carer once they are admitted to the home. The residents’ guide can be made available on audio tape, in Braille or in different languages where the need should arise. From the evidence seen by the inspector and comments received, the inspector considers that this service is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Marston Court DS0000013159.V347077.R01.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 and 10 Quality in this outcome area is poor. All users of the service have an individualised plan of care, although daily notes within their files are brief in detail and fail to evidence that care is being provided, as detailed in their care plans. Whilst the service have a robust medication policy, poor procedures are taking place which could compromise the health, safety and well being of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided to the Commission, prior to the inspection, informed the inspector that each user of the service has an individualised plan of care detailing their health, personal and social care needs and how these needs are to be met. They contain relevant moving and handling assessments as well as any risk assessments identifying any risks that could impact upon their health and the provision of care, and how these identified risks are to be minimised. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 12 However, during the inspection, three service users’ files were observed and whilst each contained a plan of care a number of shortfalls were evident. One service users file did not contain a full plan of care, when mentioned to the registered manager, the inspector was informed that the home were in the process of introducing an improved care plan format that will enable a greater focus on the individual’s wishes and preferences, and improve the accessibility of information to care staff and that this residents’ care plan had not yet been transferred over to the newer format. Further enquiry ascertained that this was the only care plan for the resident who had been admitted into the home a week prior to the inspection and since there were areas that had not been completed it failed to give the carers the relevant information to provide their care appropriately. There were a number of documents that had been left blank which included a fire risk assessment, pressure area risk assessment, admission checklist unsigned and a nutritional record which contained one entry dated 1st October for one mealtime, although notes within the file clearly stated that a detailed record be kept for 7 days. The registered manager acknowledged the shortcomings and duly sought to attend to this on the day of inspection and by the close of inspection a full plan of care was in place. However it is an expectation that there is a plan of care in place within 48 hours of being admitted to the home in order that any staff be they permanent staff or those from an agency who may be called in during times of staff sickness, annual leave etc have access to detailed up to date plans of care to ensure that they have relevant information to enable them to meet the service users needs appropriately and therefore a requirement to address these shortcomings has been made within this report. Of the two further residents files viewed, shortfalls were also evident. Where risk assessments had been undertaken the person who had undertaken the assessment did not always sign them. Furthermore, where risks has been highlighted, plans were not always in place detailing how the risks were to be minimised. This was found to be the case around nutritional risk assessments where both users were found to be at risk yet no detailed nutritional plan of care was evident and monthly weight was not always recorded. Likewise, one service users file contained a dependency tool which informed the inspector that a hoist was necessary to aid the client for bathing purposes, however, there was no mention of this within the personal care plan to alert those providing the care. A requirement has been made within this report to ensure that where a risk is identified a plan of action must be drawn up detailing how the risk is to be minimised. Daily notes within the service users files were very brief and did not always reflect the information within the care plans to evidence that care is being provided, as detailed in the service users’ individual care plans. It was acknowledged by the registered manager that this was an area that had been Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 13 highlighted through her own monitoring process and discussions with staff had taken place very recently to ensure that they enter more detailed entries within the daily notes. Each resident’s plan is reviewed regularly with input from the resident and/or their representative and updated to reflect any changes as necessary. The home has good working relationships with the local GPs and community health services and accesses them when appropriate. Since the last inspection, the service has liaised with the District Nurse regarding pressure care, who arranged for some input from the tissue viability specialist to provide staff with training in this area and which the inspector was informed was very helpful. Evidence of any healthcare treatment, which service users receive, was found to be detailed within their care plans. The home has a visiting chiropodist, physiotherapist and optician, and arrangements can be made for dentists to provide dental treatment in the home for those who require. Staff will assist service users to access these services within the community where this is their preference. Where service users wish to maintain responsibility for their own medication they are enabled to do so within a risk management process. The home has robust medication policies and procedures to ensure the health, safety and well being of those who use the service. However poor procedures were evident on the day of inspection. It was noted that medications, which have a short shelf life, are not always dated on opening to alert staff when they are to be discontinued and discarded appropriately. A requirement has been made to ensure that medication with a short life span is dated upon opening and that the Royal Pharmaceutical guidelines are followed when dealing with medication in care homes. Feedback from residents indicated that the staff treat them with respect and supported their privacy and dignity at all times. Marston Court DS0000013159.V347077.R01.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. People using the service are able to take part in meaningful activities suited to their needs and abilities and maintain contact with families, friends and the wider community. The food provided in the home is of good quality, freshly prepared and cooked on the premises, offers choice and meets the dietary needs of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with service users was generally very positive acknowledging that the lifestyle experienced at Marston Court matches their expectations and enables them to exercise choice and control over their lives, however there was feedback received from a relative who feels that there is a greater need for staff to understand the need for independence and gave an example in which the relative residing at the home ‘tries to maintain some level of independence by struggling to dress her/himself in the mornings and is Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 15 understandably upset when told later that they are to have a bath……”that it would be preferable to inform the service user the evening before giving them the opportunity to choose to remain in their nightgowns until after the bath. Since the last inspection, an activities co-ordinator has been employed and there is now a varied programme of daily activities provided for those who wish to partake. Feedback from residents and from the results of questionnaires sent to relatives, carers and advocates indicate that there is a marked improvement in this area. The activities provided are based upon the likes, dislikes and abilities of those using the service, which include art and craft, music and entertainment, bingo quizzes, cards, an exercise club, computer lessons and current affairs discussions. Outings are arranged for groups of residents and also for individual residents. There is a visiting hairdresser who visits the home once a week for those who require and the home will endeavour to access alternative therapies such as reflexology and aromatherapy if required. Service users are enabled to attend church services within the home, which are offered every third week by several visiting denominations who will visit on a one to one basis when requested to do so. The home will make arrangements to enable residents to visit their own church or for someone from their church to visit. People who use the service are provided with good quality food which is freshly cooked on the premises and are offered a choice. Special diets are available to meet residents’ health and cultural needs. The chef always endeavours to take individual tastes into account. The dining environment is relaxed and comfortable and residents are able to enjoy their lunch at their own pace. The home welcomes visitors at any time and a number were visiting at the time of this inspection. Feeback indicates that they are made to feel welcome and that they enjoy visiting. Service users are enabled to access to an interpretor where english isn’t their first language, details of which were found to be on display on the noticeboards within the home. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home has complaints and safeguarding procedures in place to protect residents from any harm arising from their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an appropriate complaints procedure in place, which is outlined in the Residents’ Guide and posted upon notice boards within the home. Discussions with service users and the feedback gained through surveys sent out to other users of the service, family members and visitors to the home, informed the inspector that they were aware of the complaints procedure and how to make a complaint if the need arose. They said that they were confident that any complaint made would be taken seriously and acted upon appropriately. The complaints procedure was available at the home and is included in the service users guide. Discussions with the registered manager ascertained that whilst no formal written complaints have been received by the home, there has been one ongoing issue with regard to rubbish bins from an outside source. A Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 17 recommendation has been made to log all verbal concerns along with actions taken and the resulting outcome. The home has systems in place to protect service users from abuse, and works to the local written protocol for safeguarding vulnerable adults. The safeguarding of vulnerable adults is taken seriously, any allegations are dealt with appropriately and staff members receive training at induction and regularly thereafter. The Commission for Social Care Inspection has not received any complaints about the home nor has it been notified of any allegations of abuse since the last inspection undertaken in May 2006. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26 Quality in this outcome area is good. Users of the service live in a well maintained environment which suits their needs and presents a high standard of cleanliness at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the premises and found that the home was cleaned to a good standard with no offensive odours present. Sufficient washing, bathing and WC facilities are available for service users use, which contain grab rails, and any specialist equipment required to ensure maximisation of their independence. Whilst touring one of the communal bathrooms there was evidence of hazardous substances being stored inappropriately in an unlocked cupboard, Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 19 this was immediately reported to a member of staff who immediately undertook the necessary precautions to ensure the health and safety of those using the service. Discussions with service users informed the inspector that they were happy with their bedrooms and their surroundings, that the home is kept to a high standard of cleanliness at all times. Service users are encouraged to bring personal possessions with them, many of which were seen to be on view in their bedrooms. A recent visit by the evironmental health officer has been undertaken in which three requirements were made, two of which the manager informed have been addressed and a further requirement made to address the flooring in the kitchen, due to recent flooding. The manager informed the inspector that the flooring is due to be replaced and is being attended to appropriately. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 20 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 good. There is a robust recruitment procedure to ensure that only suitable staff are employed to work with the users of the service, although verification of references which do not contain a company stamp needs attention. The staff team are provided with a good range of training and ongoing support and supervision to ensure they have the relevant skills and knowledge to enable them to deliver the care safely and competently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels on the day of inspection were sufficient to meet the needs of the residents. The home has a good recruitment procedure to ensure that suitable staff are employed to look after their vulnerable clients. Application forms are completed, references are collected and face-to-face interviews are undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken to ensure the persons suitability with working with vulnerable people. Two staff files were sampled for inspection which contained all the relevant pre-employment checks, references and their relevant qualifications. However, it was noted that whilst Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 21 references are sought those without a company stamp are not always followed up, for which a recommendation has been made within this report. Likewise it is strongly recommended that all CRB checks dated 2004 are repeated. All newly appointed members of staff undergo induction training upon appointment to their posts, and are provided with mandatory training, offered ongoing training and encouraged to undertake the National Vocational Qualification (NVQ) in Care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. The inspector was informed that whilst 15 of the permanent care staff have obtained their NVQ qualifications at level 2 or above in care a further 8 care staff are registered to undertake their NVQ Level 2 in Care, and a further 4 staff registered to undertake NVQ level 2 in Nutrition and Hospitality. Training provided since the last inspection undertaken in May 2006 includes dementia, fire awareness, health and safety, the mental capacity act, food hygiene, medication training and death dying and bereavement. There is a good feeling of teamwork amongst all the staff and those spoken to are very happy to be working at the home. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 22 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, 33, 35, and 38 Quality in this outcome area is adequate. Whilst the manager is qualified and has the experience to run the home competently evidence of poor procedures taking place namely around medication, the storage of hazardous substances and dealing with any identified risks appropriately do not serve the service users best interests and could compromise the health safety and welfare of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is experienced, knowledgeable, has the required qualifications and competence to manage the home although poor practices were seen to be taking place which suggests that the manager needs to Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 23 address these to ensure herself that she can discharge her managerial duties, in confidence, to senior members of staff in times of need. Residents and staff spoke in complimentary terms about her management ability and the support she gives. The management approach of the home creates an open, positive, transparent and inclusive atmosphere. Service users and staff spoke in complimentary terms about her management ability as did the feedback from surveys sent out prior to the inspection. The inspector discussed health and safety issues and saw appropriate maintenance records relating to maintaining a safe environment for residents. Regular safety checks are undertaken relating to fire safety and infectious diseases and regular servicing and maintenance of equipment, all of which were seen to be documented appropriately. The home does not act as agent or manage monies on behalf of residents. Service users’ petty cash is managed through individual accounts at a bank and records are kept of all transactions. The home engages regularly with users of the service to gain feedback on the service it provides; this is undertaken on both an informal and formal basis through feedback and suggestion forms, noting any comments or concerns when undertaking residents care reviews, resident meetings and an annual questionnaire. It is recommended that the annual questionnaire allows for family members, GP’s, social workers and any other health professionals involved with the home to take part. The home deals with a number of diverse care needs and always ensures to offer a personalised service to meet the needs of their clients. There is a commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. Whilst the manager is qualified and has the experience to run the home competently evidence of poor procedures taking place namely around poor documentation within care plans, risk assessments, medication and the storage of hazardous substances could compromise the health, safety and welfare of those using the service and do not serve the service users best interests. (see section headed Health and personal Care). Requirements have been made within this report to address these issues. In view of the above findings it is further recommended that the registered manager undertakes regular audits to ensure herself that staff adhere to the homes policies and procedures at all times, that care plans contain detailed information to enable the staff to deliver the care in a safe manner and addresses the service users’ needs appropriately thus working in their best interests at all times. Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 24 Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 25 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 4 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Ensure that all service users have a comprehensive service users plan of care, drawn up from a comprehensive assessment of need within a timely manner to ensure that residents’ needs can be fully met from the point of admission. Ensure that where a risk is identified a plan of action must be drawn up detailing how the risk is to be reduced within the care plan Ensure that medication with a short life span is dated upon opening and that the Royal Pharmaceutical guidelines are followed when dealing with medication in care homes. Timescale for action 31/11/07 2 OP8 13(4)(c) 31/11/07 3 OP9 13(2) 12/11/07 4 OP38 13(4) Ensure that hazardous substances are stored safely at all times. 31/11/07 Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP7 OP16 OP29 OP29 OP33 Good Practice Recommendations Entries made in the daily comments sheet, within service users files, should be fuller in description to allow for a full picture on the care that has been given. Any verbal complaints received about the service should be logged detailing how they have been handled and the outcomes It is recommended that any references received without a company stamp are followed up by telephone. It is strongly recommended that all CRB checks dated 2004 are repeated. It is recommended that consideration is given to including health and social care professionals, GPs and other stakeholders in the annual quality assurance questionnaires in order to gain a more rounded view of the service they are providing. The registered manager undertake regular audits to ensure herself that staff adhere to the homes policies and procedures at all times, that care plans contain detailed information to enable the staff to deliver the care in a safe manner and addresses the service users’ needs appropriately thus working in their best interests at all times. 6 OP38 Marston Court DS0000013159.V347077.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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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