Inspection on 01/10/07 for Maryville Care Home

This inspection was carried out on 1st October 2007.

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

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

Other inspections for this house

Maryville Care Home 21/08/06

Maryville Care Home 20/01/06

Maryville Care Home 24/08/05

Maryville Care Home 16/12/04

Maryville Care Home 10/05/04

Maryville Care Home 17/09/03

Maryville Care Home 16/05/03

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Maryville Care Home The Butts Brentford Middlesex TW8 8BQ Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 11:20 1st October 2007 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 Maryville Care Home DS0000022899.V348832.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. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maryville Care Home Address The Butts Brentford Middlesex TW8 8BQ 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 560 7124 0208 560 7126 margaret.oconnell@psmgs.org helen.nolan@smg.org The Poor Servants of the Mother of God Sister Margaret O`Connell Care Home 37 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Old age, not falling within of places any other category (0) Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users with Learning Disability between the ages 60 and 65 only may be accommodated. 21st August 2006 Date of last inspection Brief Description of the Service: Maryville is a Care Home for 37 older people, including older people with learning disabilities and nursing care. Male and female residents are admitted. The home was purpose built and was registered in November 2001. The Registered Provider is the Frances Taylor Foundation. The Frances Taylor Foundation is a Registered charity. The accommodation is on three floors. All the bedrooms are single rooms and have en-suite facilities, which include a shower. Each floor is a separate unit with lounge and dining area and kitchenette available for the residents. In addition there is a well-equipped kitchen where all the meals are provided. There are two passenger lifts and accessibility for wheelchair users at the home. There is a large, well-maintained attractive garden. There is a large well-equipped activity room used by the residents. The home is located within easy access to shops, local amenities and public transport. The Frances Taylor Foundation is a Roman Catholic organisation and the majority of the residents are Catholics. The home accepts residents from other faiths and supports them to attend their place of worship. There is a chapel within the home where services are held six days weekly. The unit on the second floor is for residents with learning disabilities who are above pensionable age. The ground floor unit is for residents who require personnel care only. There is a 14 bedded nursing unit on the first floor. The fees range from £468.54 to £774.54 per week, dependent on assessed need. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 16 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records & management, staff rosters; staff records, financial & administration records and maintenance & servicing records were viewed. 15 residents, 15 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors and staff have also been used to inform this report. What the service does well: The home is being effectively managed and residents living at the home are being well looked after. Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. Staff care for residents in a gentle, caring and professional manner, respecting dignity, privacy and diversity needs. The home has an open visiting policy and visiting is encouraged. The food provision is good with good variety on the menu to meet personal preferences. Complaints and adult protection issues are appropriately managed at the home. The environment is being well maintained with evidence of ongoing redecoration, refurbishment and maintenance. Infection control procedures are in place and are adhered to. The home is appropriately staffed to meet the needs of the residents. Overall systems are in place for effectively reviewing the quality of care provided and for reviewing all aspects of the home for quality assurance purposes. Any monies held on behalf of residents are being appropriately managed and securely stored. Overall the comments received via the CSCI comment cards were very positive. Examples of these are: ‘Maryville does a wonderful job of caring for resident’s physical needs-it is extremely well run.’ ‘There is a great spirit of hospitality.’ ‘The manager of the home is very available to be seen.’ ‘The service that is provided is excellent.’ ‘Good warm accommodation with carers on hand to take care of all needs.’ Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 7 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 Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 8 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.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each residents needs. EVIDENCE: The home has a pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each floor and had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls in formulating care plans where risks have been identified should be easy to address. Medications are overall being well managed on the two residential units, shortfalls in medication management on the nursing unit potentially places residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. EVIDENCE: Service user plans were sampled on each floor. Overall these were comprehensive and provided a clear picture of each resident’s needs and how these are to be met. Monthly reviews were taking place and there was evidence of input from the residents or their representatives. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 10 Risk assessments for falls had been completed. Pressure sore risk assessments, nutritional assessments, moving & handling assessments and continence assessments had been carried out however for one resident who was assessed as being high risk for pressure sores and nutrition care plans had not been formulated to address identified needs. Risk assessments for the use of bedrails had been completed and a written consent for their use was available. At the time of the inspection there were no wounds or pressure sores. Monthly weights were being recorded in the service user plans viewed. There was evidence of input from the GP and other healthcare professionals relevant to each residents needs. The medication management and records were sampled on each floor. A list of signatures was available on each floor. A medicines policy was available and this included details on the management of waste medications, however it had not been fully updated to reflect the management of leave medication. Written records were available of the current warfarin dose. Adhesive labels were no longer being used on the MAR charts. Medications were being securely stored. Liquid medications had been dated on the ground and second floor when opened. No dates of opening had been recorded on the liquid medications on the nursing unit. Dates of opening had been recorded on eye drops. Medication Administration Records (MAR) were viewed on each floor. Generally with the exception of the nursing unit these were well recorded. Where a resident was self medicating this had been clearly recorded. On the nursing unit several gaps in recording were noted, it was not clear from the records whether medication had been administered or omitted. The Inspector noted that on the nursing unit one medication that had been out of stock for several days the correct code had been used, however when the actual amount of medication received into the home was checked it transpired that only a week’s supply had been prescribed. The staff receiving the medication had not noted this. Receipt and administration of controlled drugs was clear and complete and these were being correctly stored. Blood glucose devices were checked in the home and contrary to MHRA advice the correct ones were not in use. The devices in use can potentially be a cause of infection. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Individual clothing is labelled and residents were well dressed, reflecting individuality and respecting culture and religion. Some of the bedrooms viewed had been personalised and overall there was a very homely feel, which was also commented on by visitors and in the comment cards received. Residents can have their own telephones if they so wish. On each floor it was pleasing to see staff interacting well with the residents and being able to communicate effectively with those with communication needs. Residents looked content and well cared for. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 11 In the service user plans viewed care plans had been completed for end of life care needs and wishes. Families had also completed documentation regarding being contacted in the case of health deterioration and also providing information regarding care after death. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 12 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 satisfactory, however shortfalls in providing a variety of activities, outings and entertainments does not meet the residents recreational 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 service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home has two volunteers who undertake activities within the home. Several comment cards received by the Inspector commented on the lack of mental stimulation and activity provision in the home. Comments included ‘they need to get residents out for trips and give them something to look forward to’. ‘There is a lack of mental stimulation’. Activities such as art and exercise take place. A full activities programme was not on display. The Inspector discussed possibilities of employing a full time activities person with the Registered Manager. There is a purpose built Chapel and daily services are held for those who wish to attend. For those service users who are unable to attend the daily service this can be heard via the Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 13 television in individual bedrooms and lounge areas. Several of the residents on the second floor unit attend activities and day centres within the local community. The home has a large garden and residents can attend to the raised flower beds should they wish to do so. 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 refreshments are offered. Visitors commented about the ‘homely’ atmosphere throughout. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services is available. Some residents are able to manage their own finances. The Inspector viewed the kitchen. This was clean and tidy and all the records were up to date with the exception of food temperatures. Residents are offered a choice of meals and documentation to evidence this was available. There are two meal choices for lunchtime. Residents spoken with said that they do enjoy the food and that snacks and drinks are offered throughout the day. Each unit has a small kitchenette where snacks and drinks can be prepared. The lunchtime meal was observed residents commented positively on the choices offered by the cook and that alternatives are always provided. All residents who are able to do so serve their own vegetables. On the second day of the inspection a birthday celebration was in progress. Relatives can also have a meal with their family member this is booked in advance. A range of fresh fruit was available in each dining area. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 14 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 robust system in place for the safeguarding of residents from abuse. EVIDENCE: The home has a clear complaints procedure and all concerns and complaints are documented and addressed. One complaint had been recorded since the last inspection. Residents and representatives spoken with said that the Registered Manager addresses any concerns raised promptly and thoroughly, and is very open and approachable. The home has policies and procedures in place for the protection of vulnerable adults, and these dovetail with the Hounslow Safeguarding Adults documentation. Staff spoken with said that they would report any concerns and were aware of Whistle Blowing procedures. Staff had received POVA training and the Registered Manager stated that further training had been planned. There have not been any POVA allegations since the last inspection. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 15 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained and is furnished 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 Inspector carried out a tour of each floor. Overall the home is being well maintained and there was evidence of ongoing redecoration and refurbishment. All bedrooms are single and en-suite. Fittings and furnishings are of a high standard. The home has a large garden, which, can be accessed via the ground floor. The grounds are very well maintained and garden furniture is available. The home employs one full time maintenance person and any maintenance issues are recorded in the maintenance book. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 16 All bedrooms viewed had been personalised. All the beds are adjustable and the rooms are appropriately furnished. There is a lockable space in each room. Service users can have a key to their room if they are able to manage. The Inspector viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. The washing machines have a sluice programme for infection control. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean, fresh and bright throughout. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 17 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 residents can be met. Systems for vetting and recruitment practices are in place and protect residents, shortfalls identified should be easy to address. The home does not have a comprehensive ongoing training programme, thus staff are not provided with the skills to meet the needs of residents, to include any specialist care needs. EVIDENCE: A duty roster was available. This detailed the number of nursing and care staff on duty and where additional staffing is required. The Registered Manager reported that staffing is based on the service users dependency levels. The home does not use agency staff. Where shifts need to be covered this is undertaken by the existing staff team. The home has in place a core stable staff team. A full time deputy manager is in post and works in a supernumerary capacity when the Registered Manager is not available. Both the Registered Manager and deputy manager work to provide weekend management cover. The home is clean and fresh, and each unit has their designated domestic staff. Staffing levels in the kitchen, laundry, maintenance and administration departments were satisfactory. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 18 The AQQA documentation detailed that 31 staff in the home had completed their NVQ level 2 training or hold an equivalent qualification. Further training in NVQ has been planned for 4 more staff. Staff employment files were sampled. Generally they contained all the required information under Schedule 2 of the Care Homes Regulations 2001 with the exception of details regarding ‘reasons for leaving’ previous employment. Induction training is based on the Skills for Care Common Induction Standards. This was comprehensive and was being completed by new care staff. A training matrix completed by the home was forwarded to the Inspector following the inspection. Several gaps were noted and it was not clear whether all staff had received mandatory training as well as training relevant to the needs of the residents living at the home. Training for the registered nurses to provide them with up to date knowledge and skills in line with current nursing practices is required, in order to ensure a proactive approach to care provision. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 19 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 Registered Manager is competent and skilled and has developed an atmosphere of openness and respect, thus making residents, visitors and staff feel valued. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback however some identified shortfalls should be easy to address. Resident’s monies are well managed and securely stored, thus safeguarding their interests. Shortfalls identified in staff training on health and safety does not always safeguard residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and she has completed NVQ level 4 in Health & Social Care. She has also undertaking periodic training in topics relevant to her role. Staff spoken with said the Registered Manager is supportive, approachable and has an open door policy. There are clear lines of Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 20 accountability within the home and the Registered Manager communicates a clear sense of direction and leadership and staff feel valued. Regulation 26 monthly visits are carried out on behalf of the Responsible Individual and copies of the reports from these visits are forwarded to CSCI. The home has a quality manual, which includes a self-assessment schedule. Medication audits are undertaken monthly, care plan audits are undertaken but more informally. The need to formalise these was discussed with the deputy care manager at the time of the inspection. A satisfaction survey was carried out in August 2007. Results from this audit have been collated and as a result changes have been made to the menu. Staff meetings do take place however from the minutes viewed it was not clear how often. The staff and residents who spoke with the Inspector stated that the Registered Manager and the deputy manager visit all the floors several times during the day. The home has in place a home development and business plan. There are systems in place for the management of resident’s personal monies and the records viewed were up to date. Receipts are given for all income and expenditure. Secure facilities are provided for the safekeeping of monies and valuables on behalf of residents. Servicing and maintenance records were sampled and those viewed were up to date. The AQQA documentation completed by the home did not detail this information. Concerns were expressed by the Inspector in relation to the fire alarm panel, which appeared to have not been working correctly for several weeks. The Registered Manager stated that a new fire panel was required and that this work had already been agreed. The fire engineer visited the home on the 2nd October to confirm that the system was in safe working order. The Registered Manager stated that a generic risk assessment was available. Staff had not received health & safety training and updates. See standard 30 for further details. The fire risk assessment had been updated and an evacuation plan was available. Fire records viewed indicated that staff had not always received fire training and that fire drill training for night staff was not taking place at the required intervals. Following the inspection written confirmation was sent to the Inspector that night staff had undertaken a fire drill on the 5th October 2007. Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 21 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 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 17(1)(a) Schedule 3 Requirement Where a residents pressure sore or nutritional risk assessment is assessed as high risk a care plan to reflect this must be in place, to ensure that the residents identified needs are being met. The home must expand its medicines policy to include the management of waste medicines in the home and leave medication. Previous timescale of 01/10/06 partially met. Liquid medications must have the dates of opening recorded to ensure the safety of the resident. The home must ensure that sufficient medication is prescribed to ensure that the residents medication needs are met. Professional finger pricking devices or lancets for professional testing must be used in the home to prevent the risk of infection Medicines must be recorded accurately when administered. There must be a full programme of activities to include indoor and DS0000022899.V348832.R01.S.doc Timescale for action 11/11/07 2. OP9 13 (2) 05/11/07 3. 4. OP9 OP9 13(2) 13(2) 05/11/07 05/11/07 5. OP9 13(2) 05/11/07 6. 7. OP9 OP12 13(2) 16(n) 05/11/07 01/12/07 Maryville Care Home Version 5.2 Page 23 8. 9. OP15 OP29 12 Schedule 2, 19 outdoor activities for each floor to ensure that the home meets the residents assessed needs. Temperature records of cooked food must be kept up to date to ensure the residents safety. Staff records must contain the information as required by Schedule 2 of the Care Homes Regulations 2001. Previous timescale of 01/10/06 partially met. An action plan for training to include all mandatory training with timescales for completion must be formulated and a copy forwarded to the CSCI, to ensure that the staff working at the home have up to date skills and knowledge. Fire drills for night staff must be undertaken at the required intervals and clearly recorded to ensure the safety of the residents, staff and visitors. 05/11/07 11/11/07 10. OP30 OP38 18 01/12/07 11. OP38 23(4) 05/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. Extracts may not be used or reproduced without the express permission of CSCI Maryville Care Home DS0000022899.V348832.R01.S.doc Version 5.2 Page 25 - 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. 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