Inspection on 30/06/08 for Martin House

This inspection was carried out on 30th June 2008.

CSCI found this care home to be providing an Adequate service.

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:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Martin House 1 Swift Road Southall Middlesex UB2 4RP Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 10:15 30 June & 1st July 2008 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 Martin House DS0000071572.V364643.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. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Martin House Address 1 Swift Road Southall Middlesex UB2 4RP 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) 0208 307 3300 Servite Houses Marnie Brillantes Reed Care Home 75 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (45) of places Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission are within the following categories: Old age, not falling within any other category - Code OP (Maximum number of places: 45) Dementia - Code DE (Maximum number of places: 30) The maximum number of service users who can be accommodated is: 75 New Service 2. Date of last inspection Brief Description of the Service: The home has been purpose built to meet the National Minimum Standards for Older People. It is situated in a residential area of Southall, and is easily accessed via public transport. There are shops and a Post Office within walking distance to the home. The home comprises of 5 units, each of which can accommodate 15 residents. All bedrooms are single with en suite toilet, wash hand basin and shower facilities. Each unit has a communal sitting/dining area with a kitchen area plus a separate quiet room and activities room. Two of the units are registered to provide dementia care and three units are registered to provide general care. Each unit is individually staffed. The home accommodates residents placed by the Borough of Ealing. At the time of inspection one unit was still to be opened and the other 4 units were steadily taking admissions. The following information regarding fees has been provided by Servite Houses: ‘Martin House was developed under the Governments Private Finance Initiative and capital costs are met in this way. Ealing Council pays a unitary charge, which covers all the services the council receives from Ealing Care Alliance. It covers the costs of care and the provision of facilities management services to the day care service and accommodation. It is not possible to separate these out to identify how much each residential care and nursing care placement costs. The fee payable to the council by residents who fund themselves in full is Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 5 £526.00 per week for residential care. The fee payable to the council by residents who fund themselves in full is £651.00 per week for nursing care. Deducted from that will be the ‘free nursing care’ amount of £125.00 (high) and £83.00 (medium and low). Private funders are also welcomed for which a fee is negotiated based on individual care/nursing needs.’ Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 26 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication management & records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 18 residents, 14 staff and 8 visitors were spoken with as part of the inspection process. The Annual Quality Assurance Assessment (AQAA) was also completed and has also been used to inform this report. It is acknowledged that the home was given short notice to complete this document. A number of our surveys for residents, representatives, staff, healthcare professionals and care managers had been sent to the home, however few were received back and there appeared to be some confusion regarding completion of these documents, so we have not been able to include any comments. What the service does well: What has improved since the last inspection? This was the first inspection of this home. Martin House DS0000071572.V364643.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. Martin House DS0000071572.V364643.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 Martin House DS0000071572.V364643.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): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: The home has a comprehensive pre-admission assessment document and completed assessments were viewed on each unit. Some were incomplete and contained quite brief information. The importance of ensuring that the documentation is completed in full and where information is not available a record should be made, was discussed. Copies of resident assessments carried out by Social Services were available for all resident files viewed, and provided a good picture of the residents’ needs. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 10 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 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In most cases the service user plans were reasonably completed, however omissions in information could lead to individuals personal and healthcare needs not being fully met. Generally medications are being adequately managed, however shortfalls could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Information regarding end of life care wishes is limited, however the Registered Manager is aware of the need to discuss this with residents and their families, to ensure their wishes are identified and met. EVIDENCE: On the personal care units 3 service user plans were viewed. Overall these were well completed and provided a good picture of the residents needs. There was evidence of monthly reviews and updates. There was evidence that residents and their families had been involved in the assessment process and had provided information included in sections of the service user plans, however they had not been involved in signing to evidence their involvement in the formulation and review of the service user plans. The Registered Manager Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 11 said that this topic would be discussed with residents and also at the planned relatives meeting. Risk assessments for falls had been completed and monitoring forms for recording any falls were also available. For one resident receiving respite care some information had not been fully included, however this had been addressed by the second day of inspection. The home has a lot of referrals for respite care and the need to review and possibly simplify the documentation used for these admissions was discussed. On the nursing care units 3 service user plans were viewed. Nutritional assessments and pain assessments had not been completed in the service user plans viewed on both units. Continence assessments and moving & handling assessments were available on both units, and moving & handling equipment in use for each individual had been identified. Some of the information in the care plans was very general and needed personalising, and there was no evidence of residents and their representatives being involved in the formulation and review of the service user plans. On the general nursing unit there was a lack of information for specific and significant medical care needs and the importance of including this detail was discussed. It was also confusing that in some instances information appeared to be recorded for the wrong person, and it would seem that information had been copied from another individuals care plan. Wound care documentation was viewed. There were not individual care plans for each wound and the dressing regimes were difficult to identify, therefore it was not possible to follow the progress of each wound. The pressure sore risk assessment score had been incorrectly scored and we were told that photographs of wounds had been taken, however these were still to be printed. It is noted that a referral had been made to the tissue viability nurse who had in turn visited and reviewed the wound care. The home has ordered high risk pressure relieving equipment and this is now in use for residents with pressure sores or those at high risk of developing them. Bedrail assessments had been carried out, however there was no evidence of written consents for their use. On the dementia care nursing unit some of the specific nursing needs had been personalised, however this needs doing for each need identified. Care plans for dementia care and mental health care needs were in place. Again there was no evidence of input from residents and their representatives, which is to be discussed. Medication management was viewed on each unit. Lists of staff signatures and initials were available. Appropriate single use lancing devices for blood glucose monitoring were in use. Administration records were complete and where a medication had been omitted for some reason, the correct coding with an explanation for the omission had been used. With one exception, receipts, to include those for medications received mid-month had been recorded. Records of disposal were available, and the need to ensure that all medications are disposed via the clinical waste collection service was discussed at the time of the inspection. Room temperatures were regularly above the safe level of 25° centigrade and the fans available do not appear adequate to keep the Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 12 temperature under control. Minimum, maximum and actual temperatures for the medications fridges on the personal care units had been recorded and were in safe range, however gaps in temperature recordings were noted on the nursing units. Entries in the controlled drugs register viewed on a nursing unit were completed, however the need to ensure both staff sign their names in full was discussed. Liquid medications to include eye drops had been dated when opened. For residents admitted for respite care they sometimes come in with liquid medications that have been opened, and the need to find a satisfactory way of identifying and recording this was discussed. On the personal care units, where residents have been admitted with medication in boxes, a clear stock balance is recorded and ongoing records are maintained, to ensure good stock control. For residents on medications with very specific administration instructions, these had not always been recorded in full on the medication administration record (MAR) or the instruction label on the box. Stock balances had been carried forward onto the new MAR. On the nursing dementia care unit labels had been provided for the MAR for new medications and this practice is unacceptable as labels are not a permanent record. Any entries for such medications must be hand written until the next MAR is printed. On the personal care dementia care units an allergy had not been recorded on the MAR, plus where one medication dosage had changed the entry on the MAR had not been re-written to fully reflect this. One resident on a personal care unit with diabetes was prescribed insulin twice a day. The district nurse was drawing up insulin twice a week in two different doses for each day and leaving in the fridge for care staff to select and administer in their absence. Advice from the National Patient Safety agency is that insulin should not be prepared more than 24 hours in advance. The Royal College of Nursing also views the practice of pre-mixing/pre-loading insulin as necessary only after all other options have been exhausted. This is to meet manufacturers recommendations, to prevent errors in selecting the wrong dose and also to allow timely changes in dosage adjustments. The units had up to date copies of the British National Formulary, containing information about all medications. Medications are being securely stored on each unit. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Staff were seen interacting well with residents and there was a good atmosphere throughout the home. Residents looked well cared for and were dressed to reflect individual and cultural preferences. Staff were seen knocking on residents doors and overall there was a attitude of respect for the residents. Staff are available to speak with residents in their own languages and gender care preferences are clearly identified in the care plans. There is an Asian television channel available, however residents would also like an alternative channel to meet their regional needs, which the Registered Manager is to investigate this. The care plans for health deterioration and end of life care wishes contained limited information. The importance of providing residents and their families with the opportunity to discuss this topic was highlighted, and the Registered Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 13 Manager said that she would do so at meetings with residents and relatives. It is acknowledged that this is a sensitive area of care, and if people do not wish to discuss it as yet then this can be recorded. Martin House DS0000071572.V364643.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is in progress, to provide a variety of activities entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet residents individual dietary needs. EVIDENCE: The home has recruited an activities co-ordinator and is waiting to receive the required employment checks. An activities programme is on display and information regarding residents’ interests recorded in the care plans. On the personal care units staff were facilitating activities, although this was not seen on the nursing units. The Registered Manager is planning a ‘snoozelen’ room for relaxation and is also developing a Life Skills centre within the home, which will develop from the life history information to be obtained for each resident. It is acknowledged that once the activities co-ordinator is in post work in this area can be advanced. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 15 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and kept up to date with their relatives’ condition. Residents can receive visitors in one of the communal rooms or in their bedrooms, as they so wish. The home has information regarding Age Concern Advocacy Services on display in the home. All the residents are placed by Ealing Social Services, and residents have access to the Care Managers at Social Services should they have any issues with which they need assistance. We viewed the kitchen. The area was clean and tidy and records were up to date. The home has a 4 week menu and choices are available at all meals. Each unit has a kitchenette area where drinks and snacks can be prepared. The home has a unit for Asian Elders and the catering service provides meals to meet cultural needs. Residents spoken with said that they enjoy the food and are offered a choice, and documentation was available to evidence this. Staff were seen assisting residents with their meals where needed, and also gently encouraging and supervising residents, promoting their independence. Martin House DS0000071572.V364643.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 & 18.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a system in place for the safeguarding of service users from abuse, understood by staff, thus protecting residents. EVIDENCE: The home has a clear complaints procedure, and a copy is displayed on each unit. The Registered Manager said that it had become clear that some visitors were unsure how to make a complaint and this topic is to be discussed at the forthcoming relatives meeting. The home had received 2 complaints, plus 1 received by the Area Manager. These had been recorded and investigated. The Managers both stated that verbal feedback had been given to the complainants, except where the complaint had been anonymous, so could not be responded to. The home has procedures in place for safeguarding adults and also follows the London Borough of Ealing Safeguarding Adults procedures. Staff spoken with were very clear regarding the reporting of any concerns and also of Whistle Blowing procedures. There have been 4 incidents referred under Safeguarding Adults procedures. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has been purpose built to a high standard, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The home is purpose built and was opened in February 2008. The premises have been equipped and furnished to a high standard, and the units are homely and welcoming. Each unit has 15 bedrooms, a sitting/dining room and a separate activity/quiet room. The home has a Day Centre attached to it and this has not as yet opened. There is a secure garden and this plus the car park are to be shared between the home and the Day Centre. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 18 The bathrooms are spacious and well equipped to meet the needs of the residents, plus each bedroom has an en suite to include toilet, wash hand basin and assisted shower facilities. The corridors are wide and there are handrails on each side. There is moving & handling equipment available and staff stated that the equipment available meets the needs of the residents. The home was furnished with manual hospital beds, and the Registered Manager is in the process of purchasing profiling beds for residents with high care needs. All the bedrooms are single and the en suites include toilet, wash hand basin and shower facilities. The bedrooms are spacious and furnished to a high standard, and residents are encouraged to personalise their rooms, giving a homely feel. The home has a separate laundry room with 2 washers and 2 dryers, all of industrial standard. There are clear laundry programmes on display and the washing machines have appropriate wash programmes to manage soiled or infected laundry. Unless otherwise indicated, personal clothing is laundered ‘per unit’ so that any unlabelled items are returned to the correct unit for identification. Protective clothing to include disposal gloves and aprons were available in the home. The home was clean and fresh throughout, and infection control was being well managed at the time of inspection. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 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. 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. The home is appropriately staffed to ensure that the needs of the service users are met. Systems for vetting and recruitment practices are in place and protect residents. There is a training programme, to provide staff with the skills to meet the needs of residents. EVIDENCE: Each unit is separately staffed and the Registered Manager stated that staffing is based on dependency levels. The general nursing unit has several residents who have very high dependency needs and the staffing had been recently increased to reflect this. On the dementia care nursing unit some residents required close supervision. We were concerned that if staff are allocated to supervise these residents, then there are implications for being able to fully meet the needs of all the residents on the unit, and this needs to be reviewed. The staffing on the personal care units was appropriate to meet the needs of the residents. The Registered Manager said that apart from ensuring that there are always staff on the Asian Elders unit who can communicate effectively with the residents, there are also staff on the other units who can ably communicate with the residents. The Registered Manager said that at present they did not have a maintenance person, however the administrator plus maintenance staff from other areas are temporarily carrying out this work. Other ancillary staff are employed to meet the needs of the home. The home Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 20 does use agency staff, and has continuity of staffing from the agency. Relevant employment information is provided by the agency to the home. There are 9 staff who have provided evidence of NVQ in care training to level 2 or above. There are several other staff who are to bring in their certificates to evidence completion of this training. Further NVQ training is being planned for September 2008 and the Registered Manager is aware of the need to ensure a minimum of 50 of care staff are qualified to NVQ in care level 2 or above. The Area Manager explained that for staff who are not undertaking this training, they are looking at specific areas of training to provide them with individual skills to enhance resident care. The home has just received the staffing records from head office, and some of the documentation was not available to view. However there is a checklist on which a record of all employment checks are kept. The up to date version was sent through to the home at the time of inspection. The Area Manager explained that the robust system in place means that staff cannot be employed until all the information required under the Care Home Regulations 2001 has been received. Servite Houses have an induction programme based on the Skills for Care Common Induction Standards. Staff spoken with said that they had received 5 days induction training, and there is a rolling 4 day programme of induction, repeated on a monthly basis so that all staff receive induction training promptly after commencing employment. The Registered Manager did not have examples of completed induction training booklets available to view, and there appeared to be some confusion as to whether new staff had actually been provided with this booklet. The need for evidence that all staff complete the induction booklet was discussed. The Regional Manager has since confirmed that the Head of Care had been ensuring that new staff receive and complete the induction booklet. She has also confirmed that she has discussed this with the Registered Manager and the Head of Nursing. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team in place are effective and ensure that the home is being well managed, thus enhancing the lives of the residents. Systems for quality assurance are being developed, to provide an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are in place, thus protecting residents, staff and visitors. Shortfalls should be easy to address. EVIDENCE: The Registered Manager has completed the Registered Managers Award and is also qualified to NVQ level 4 in care. She has experience in elderly and dementia care and has had management experience since 2004. Staff spoken with said that the Registered Manager is supportive and approachable. The Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 22 home also has a registered nurse who is Head of Nursing and a Head of Care, both of whom are in management positions and work on a supernumerary basis. The roster viewed evidenced some weekend management cover, and we recommended that the management cover at weekends and at other ‘out of hours’ times be reviewed. The Registered Managers office is located on the first floor, and the need to ensure that there is clear signage to tell visitors and residents where they can access the Registered Manager was discussed. The home has been registered since February 2008 and the Registered Manager is in the process of building up the quality assurance programme for the home. A comprehensive monthly audit is carried out for the London Borough of Ealing, which covers in detail all aspects of the home. Regulation 26 visits are carried out monthly on behalf of the Registered Provider and copies of the reports are available. Staff meetings take place regularly and minutes are available. The Registered Manager has a relatives meeting planned, and it was clear that she had considered several points for discussion at this meeting, to disseminate information and promote input from relatives. The home holds clear records of income and expenditure for residents for whom monies are held on their behalf. Receipts were available for all expenditure and the records were accurate and up to date. Samples of installation, servicing and maintenance records were viewed and those seen were up to date. The Area Manager stated that she was to meet with the Facilities Management Team to discuss which areas of maintenance are to be completed by them and which areas are to be completed by the home staff. A risk assessment for the premises had been carried out on March 2008 and the Fire Risk assessment was last updated in June 2008. There was only one fire drill recorded since the home opened, and the importance of ensuring that fire drills for day and night staff are carried out at the required intervals was discussed. Staff had received training in health & safety topics and the training matrix evidenced this. New staff do not use moving & handling equipment until they have received their training in this area. The Registered Manager said that she has plans for 2 staff to undertake moving & handling instructor training, to provide in-house training and updates in the future. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 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 4 X 4 3 X 4 X 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 X 3 X 3 X X 2 Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Care plans must be complete for each identified need and the information contained therein must be personalised, up to date and accurate, to reflect the needs of each individual and how these are to be met. Unless it is impracticable to do so, input from residents and their representatives must be sought in the formulation and review of the service user plans, so that their wishes are recorded and respected. Assessments must be fully and accurately completed and kept up to date, to reflect the condition and needs of each resident in each healthcare area assessed. Wound care documentation must be complete and up to date, clearly reflecting the progress of each wound. Following assessment, written consents for the use of bedrails must be obtained to evidence that there is agreement to their use. DS0000071572.V364643.R01.S.doc Timescale for action 01/09/08 2. OP7 15(2)(c) 01/09/08 3. OP8 17 01/08/08 4. OP8 17 01/08/08 5. OP8 13(7) 01/08/08 Martin House Version 5.2 Page 25 6. OP9 13(2) 7. OP9 13(2) 8. OP9 13(2) 9. OP11 12 10. OP38 23(4) Action must be taken to maintain the temperature in the medications rooms below 25° centigrade so that medications are stored at safe temperatures. Daily monitoring of fridge temperatures must be maintained. Those responsible for the administration of medications must be aware of any specific administration requirements and these must be recorded on the MAR. Administration instructions must be clearly recorded on permanent ink on the MAR. That the practice of supporting residents in the residential unit, with insulin drawn up 3-4 days in advance, is reviewed with the district nurse team. Information regarding service users wishes in the event of deterioration in their health, plus their care in their final days must be ascertained and recorded, so that their wishes are respected. Fire drills for all staff must take place at the required intervals to ensure that residents are safeguarded. 18/07/08 18/07/08 18/07/08 01/09/08 18/07/08 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. Refer to Standard OP3 OP12 Good Practice Recommendations That the pre-admission assessment carried out by the home staff be completed in full to provide a clear picture of the prospective resident and their needs. That staff ensure activities are being carried out on all units in line with the activities programme, to ensure that DS0000071572.V364643.R01.S.doc Version 5.2 Page 26 Martin House 3. 3. OP27 OP30 activities are available to all residents if they wish to partake. That the staffing on the dementia care nursing floor be reviewed in the light of some residents needing constant supervision. That all staff are kept up to date with induction training information to ensure all new staff receive full induction training. Martin House DS0000071572.V364643.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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