Inspection on 01/09/05 for Merrivale

This inspection was carried out on 1st September 2005.

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

Other inspections for this house

Merrivale 10/11/08

Merrivale 14/11/07

Merrivale 29/05/07

Merrivale 02/03/07

Merrivale 26/04/06

Merrivale 25/04/05

Merrivale 09/11/04

Merrivale 02/06/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Merrivale 90 East Road Burnt Oak Middlesex HA8 0BT Lead Inspector Rebecca Bauers Unannounced 1 September 2005 @ 11.00am 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 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. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Merrivale Address 90 East Road, Burnt Oak, Middlesex HA8 0BT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8952 7639 020 8951 5310 Carole Sawyers for Fremantle Trust Vacant Post (acting manager Gillian Smith) PC Care Home only 56 beds Category(ies) of MD(E) Mental Disorder over 65 registration, with number DE(E) Dementia over 65 of places OP Old Age Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None 25 April 2005 and 25th July 2005 (pharmacist visit) Brief Description of the Service: Merrivale is registered to provide care to fifty-six service users over the age of 65, who have a mental health diagnosis or a diagnosis of dementia. The home has transferred from local authority responsibility to being run by Fremantle Trust. Date of last inspection The home is divided into eight units and includes two dedicated respite units one of which is for people with dementia. The units accommodate between five and nine service users and have lounge, dining room and kitchenette. The units are staffed separately. The building has three floors. The ground floor has one respite unit and one mainstream unit. The second floor has one respite unit and two units for people with mental health needs. The third floor has one mainstream unit and two units for people with dementia. There are mature gardens to the front and rear of the premises. The overall aim of the home is: “To provide a high standard of care and support that is tailored to meet individual needs taking account of each service users right to exercise choice and self-determination in pursuing their own lifestyle.” Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 1st of September 2005 as part of the annual inspection programme to identify progress with previous requirements and to check standards of care against the core standards. Progress was also checked following an additional visit carried out by the pharmacist inspector on the 25th of July. The inspection took five and a half hours to complete. A partial tour of the home took place, ten service users were spoken to in small groups and on and individual basis. Care records and health and safety records were examined. Four staff were spoken to and the acting manager was present throughout the inspection. What the service does well: What has improved since the last inspection? Eleven of the eighteen requirements made at the last inspection and during an additional visit on the 25th of July had been achieved. Seven requirements were restated at this inspection. The administration of medication and ensuring that records are completed appropriately including the controlled drug register had much improved to Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 6 safeguard service users. Temperatures of the medication cupboards are recorded; the returns book is now being signed by the pharmacist. All service users have updated medication profiles that correspond with the medication sheets and there is a clear audit trail for medication ordered and received into the home. The smell of urine in two of the units has now been eradicated ensuring a more pleasant environment for service users, visitors and staff. Regular reviews of the food provided in the home are now being undertaken in order to meet the preferences of service users ensuring that the menus remain nutritionally balanced. Staff who handle food now have food hygiene training to ensure the safety of service users Additional staff cover during specific times of the year when service users wish to go out has been arranged and is in place. Two references had been obtained for one member of staff to ensure the safety of service users. Information had also been obtained to clarify her leave to remain in the UK. The newly appointed manager has applied to the CSCI to become registered. What they could do better: Sixteen requirements were made at this inspection. Seven were restated and four recommendations were restated. Requirements were made for a thorough assessment to be carried out for the service users who receive respite care and for individual plans of care to be in place including a nighttime plan of care. Other areas needing improvement concerned updating the staff list who have been trained to administer medication, the storage of medication in two of the units, the labelling of eye drops and the administration of prescribed creams to safeguard service users and staff. Further requirements concerned staff training files and staff training needs to meet the needs of the existing service user group and the ever changing service user group that use the respite service. Maintenance remains an ongoing issue with many areas requiring refurbishment to improve the environment for service users. Staffing levels at night need to be increased to meet the high dementia care needs of the service users on the top floor of the home, further consideration must be given to additional staff cover in the respite units given the differing Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 7 needs of service users and the slow response times to the call bell. This must be addressed as a matter of urgency to ensure the health, safety and welfare of service users. A requirement was made for the actions identified following an adult protection strategy meeting to be complied with. This concerned three complaints made to the local authority with regard to the care received in the respite units. Further requirements were made for the recommendations made and the enforcement notice issued following a recent fire inspection by the LFEPA to be complied with to safeguard service users and for all fire doors to be kept shut. Occupational therapy assessments should be carried out for service users who use the respite service to ensure that suitable adaptations are in place. 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. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 Service users can not be sure that their assessed needs will be met because the information obtained is not always consistent or detailed enough to achieve this. Service users do feel however that their needs are generally being met by helpful and caring staff. EVIDENCE: Two of the three files examined in one of the respite units did not contain detailed assessments, in one case the initial assessment carried out by a GP highlighting specific needs for one individual had not been included in the homes assessments and so important information with regard to the individuals mobility had been omitted. This indicated that staff are not fully aware of the service users mobility needs. Some service users needs had been documented fully and others were very sparse there did not appear to be a consistent range of information obtained at the assessment stage either by the placing authority or the home. This must be rectified to ensure that this information is used to develop full individual plans for service users so that they can feel confident that staff understand there needs. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 10 Service users spoken to said that the staff were “very kind, helpful and caring.” They felt that staff generally know and are able meet their needs, although staff would benefit from training in areas such as Parkinson’s disease. Service users spoken to confirm that they would return to the home for respite care others said that they already spend regular time receiving respite care that they are happy with. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9,10 The service user’s health, personal and social care needs are not clearly set out in the individual plans of care this specifically relates those service users who receive respite care. Staff are now working within the home’s medication policies and procedures, some issues remain with regard to storage of medication in two of the units. Service users are treated with respect and their rights to privacy are upheld. EVIDENCE: Service user individual plans were incomplete for service users receiving respite care. As a result there was no clear indication for staff with regard to service users individual support needs relating to their health, personal and social care needs. None of the service users had a night- time care plan nor had a record been kept of service users nighttime activity or if any assistance had been given during the night. This must be recorded so that appropriate risk assessments are in place to safeguard service users. Service user files were not holding information in the most accessible or logical way, it is recommended that they be organised in a more appropriate way to ensure that all information is accessible to all staff. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 12 Requirements made at the last inspection and during an additional visit by the pharmacist inspector related to the administration of medication had been progressed. A requirement made for the administration of medication in the home to be accurately recorded and any refusal appropriately signed for had been complied with. No gaps were found in four of the five records sampled for the administration of medication, Controlled drug records had been signed by two staff following administration. The list of staff trained and authorised to administer medication dated 2001 still needs to be updated in accordance with recent medication training. Medication returned to the pharmacist is now being be signed by the pharmacist to evidence receipt of medication. Further requirements made by the pharmacist inspector for the medication profiles to be kept up-to-date and in agreement with the information on the Mar sheets had been complied with to ensure service users are receiving the correct medication. The temperatures of the areas where drugs are stored are being recorded, two care staff are now checking the that all medication ordered and received is in adequate supply to ensure service users always have the correct medication available at all times. The registered person is still not ensuring that the date when eye drops are opened are recorded on the bottle to ensure that they are only used for the correct time after opening. This must be rectified to safeguard service users. The registered person still needs to ensure that there is sufficient space on Collingwood and Eastview to enable staff to enable staff to administer medication in a safe and efficient manner. The acting manager said that medication trolleys will be purchased. In some cases service users are prescribed creams to be applied on different part of the body. This had not been stipulated on the MAR sheets nor was there any guidance for staff to safeguard service users or staff where creams were needing to be applied to intimate parts of the body. This must be rectified. Service users spoke positively with regard to the care that they receive from staff stating that they always respect their privacy and dignity whilst being provided with personal care and that they are spoken to with respect. Service users stated that staff are familiar to them and that they have a good relationship with them. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Service users lifestyle expectations and recreational needs are being met more frequently to enable them to lead fulfilling stimulating lives. Service users do maintain good regular contact with family and friends although there are no representatives from the local community visiting individual service users. Food provided is wholesome and balanced and is now more appealing to service users. EVIDENCE: Some service users spoken to felt more satisfied with the recreational activities provided in the home and the more frequent visits to the pub, shops or café. One service user does voluntary work and is due to start running a trolley shop within the home. An additional member of staff had been added to the rota as a ‘float’ following a requirement made to enable service users to get out to the local shops and provide a little more flexibility. Service users continue to maintain contact with family and friends on a regular basis, during the inspection day a number of relatives visited the home. Service users were seen participating in group activities for example, armchair exercises, listening to old time music, watching black and white films and playing puzzle games. Others were seen reading, listening to the radio and Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 14 watching TV in their own bedrooms. Outside entertainers have been booked on a monthly basis. A recommendation made at the last inspection for a befriender or volunteer to be employed had not yet been progressed. Discussion with regard to the food provided was more positive than at the last inspection. A new cook had been recently employed who had up-to-date certificates in food hygiene training. Alternatives to the four week menu are offered and specialist dietary requirements such as low fat or reduced sugar for diabetic service users is provided and listed in the kitchen. The new cook regularly consults with service users with regard to food preferences. Mealtimes are flexible and are provided to meet individual service users preferences. At a recent service users meeting (28/7/05) service users requested a barbecue, pub lunches and changes to the breakfast menus. The storage of food in the freezer is now acceptable. All staff involved in handling food have planned food hygiene training for 20/9/05. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Service users do feel confident that their concerns are listened to by staff and acted upon. Recent complaints are being investigated fully and actioned. Staff are adequately trained to protect service users from abuse. EVIDENCE: There have been three complaints made directly to the placing authority since the last inspection with regard to the care received particularly by service users receiving respite care. A strategy meeting was held on 5th July 2005 and an action plan had been developed to address the issues. The home had made some progress to make changes to the care provided and to put safeguards in place to prevent these errors occurring again. Some progress had been made to meet the actions however there are still outstanding issues that need to be addressed and these had been identified during the inspection. Requirements had been made accordingly in the appropriate section of the report. The home has a clear complaints procedure in place that is readily available to service users. Service users also had a copy of the commission address and telephone number in their rooms if they had issues they wished to discuss. Service users spoken to confirm that they felt at ease with staff to share any concerns. The complaints record showed that the home had received two complaints since the last inspection, the complaints had been investigated and outcomes had been fully documented. Six compliments had been received from either service users or relatives with regard to the care received in the home including the respite units. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 16 Service users are protected from abuse, staff spoken to had recently received adult protection training and are familiar with the reporting procedures in the event of an allegation of abuse. The home has robust adult protection procedures in place. The registered person must ensure that the actions raised at the last strategy meeting are complied with fully to safeguard service users. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,23,26 Service users live in a safe environment that is however in need of serious redecoration. Bedrooms are comfortable and personalised; aids and adaptations are available to meet service users mobility and safety needs. The response time to the emergency call bell by care staff must be reduced to safeguard service users. EVIDENCE: Service users spoken to stated that the response time for answering the call bell was too long, sometimes service users had to wait 30 minutes for assistance from the care staff, this seemed to be the case more in the respite unit and at night. This must be rectified to safeguard the health, safety and welfare of service users. At this inspection and during a tour of part of the building it was evident that no progress had been made with regard to the redecoration building. The requirements have therefore been restated Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 18 The following areas need to be addressed and re-decorated: 1. In one particular kitchen the cooker was old and tired looking and needed replacing. 2. Communal areas are tired and in some places dark, these must be redecorated, including woodwork. 3. In some cases service users wallpaper in their bedrooms was coming away from the walls this must be replaced. 4. In one of the units on the ground floor the assisted bath is not used by service users because they prefer a hoist assisted bath and so are currently using the bath in another unit. Consideration must be taken to replace the bath with one that suits the preferences and need of the service users. The acting manager explained that the maintenance person had identified that a great deal of maintenance is work needed to make the home more comfortable and homely and that a maintenance plan is in the process of being developed and will be submitted to the Commission as per the requirement. Service users individual bedrooms had been personalised with their own possessions and were safe. The home is clean and hygienic, the two units that smelt of urine have now been cleaned and flooring replaced. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Service users needs are not being fully met by the numbers and skill mix of staff. Staff training records are incomplete and not all staff are suitably competent to meet the differing needs of service users in the respite units. EVIDENCE: The staffing levels in the units are based on the level of need of the service user group; there is an additional ‘floating’ member of staff on duty that acts as extra cover as and when needed. An additional ‘floating’ member of staff has been introduced since the last inspection which has given service users a level of independence and flexibility with regard to accessing the community even for short period of time. The staff rota still does not provide clarity with regard to staff roles, start times and colour codes this must be rectified to ensure that all staff can understand the rota. The rota for the respite care units did not always have sufficient staff on duty to meet the needs of the service users. One service user in particular requires 1to1 support, this was available according to the rota in the morning but not for the evening, the lack of adequate staffing puts service users and staff at risk. There needs to be sufficient flexibility in the staff levels to ensure that sufficient staff are on duty to meet the service users needs. This must be rectified. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 20 Currently there are four waking night staff covering three floors. So one staff member per floor and a ‘float’ between floors. Some service users on the upper floor have high dementia care needs and require the assistance of two staff during the night, in addition as mentioned previously the response times to the call bell is slow, it would seem that this is partly due to the low number of staff working at night and the higher needs of the service users, this must be rectified to ensure the safety of service users at night. Service users spoke very positively about the staff stating that they were ‘great, don’t know what we would do without them’, ‘ staff are very caring and helpful I can’t fault them’. Staff were seen interacting positively with service users and some staff had been working in the home for five or more years. The 30-40 hour a week vacancy must still be recruited to. Staff training files were still incomplete and must be reviewed to identify current training needs to ensure that staff are competent to support the service user group. Training still needs to be provided to reflect the current service users mental health issues such as schizophrenia and anorexia. Staff must receive training to meet the needs of those service users with Parkinson’s or who are recovering from strokes. Staff stated that IT training would benefit them in the development and revision of service users individual plans. Staff acknowledged that they had received training in medication administration, first aid, equal opportunities and some mental health recently. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,38 The acting manager has applied to the CSCI to become registered. Staff morale is good. Service users views are listened to, to ensure that their best interests are accounted for. The health welfare and safety of service users are not fully promoted and protected following and enforcement notice issued by the fire brigade. EVIDENCE: Staff morale is good; staff described positive team working which helps to create a happy relaxed atmosphere for service users. The management of the home is open and inclusive. The recently recruited manager has applied to the CSCI to become registered. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 22 Quality assurance audits that involve service users demonstrate that the home is working toward running the home in the best interest of the service users. Action plans have been developed to address the issues raised by service users including food provided. Service users have regular meetings where they are able to express any issues or make suggestions. The health, safety and welfare of service users are promoted and protected; all relevant records and certificates were in place. A recent fire inspection took place where an enforcement notice was issued. Most of the recommendations had been actioned; the registered person must ensure compliance with the enforcement notice to safeguard both service users and staff. All staff spoken to were aware of the what to do in the event of a fire. Alarms were sounded during the inspection and fire doors were seen to close automatically. Fire exit doors were able to be opened freely. Some of the fire doors had been propped open this is not acceptable all fire doors must closed or suitable self closing devices must be fitted and two fire doors had large gaps at the bottom these need to be replaced. It was clear that in some cases service users would benefit from an occupational therapy assessment to ensure suitable adaptations are in place, for example higher sitting positions. Office files needed were still not always easily identifiable; it is recommended that the filing system be reviewed to make information more accessible for all staff. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 1 x x 2 3 x x 3 STAFFING Standard No Score 27 1 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 3 x x x x x x 1 Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Requirement Timescale for action 1/10/05 2. 19 23(2)(d) 3. 27 18(1)(a) 4. 30 17(2)(3) The registered person must ensure that the list of trained authorised staff to administer medication must be reviewed and updated in each medication file. This requirement is amended and restated from the last inspection. Timescale for action was 30/6/05 The registered person must 1/10/05 provide a maintenance plan to address the re-decoration of the home including the replacement of some of the cooking facilities in individual units. A copy of the maintenance plan must be sent to the CSCI. This requirement is restated from the last inspection. Timescale for action was 31/7/05. The registered person must fill 1/10/05 the 30-40 hour a week staff vacancy by employing permanent staff. This requirement is amended and restated from the last inspection. Timescale for action was 26/5/05. The registered person must 31/1/06 ensure that the staff training files are reviewed and updated Version 1.40 Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Page 25 5. 30 18(1)(c ) 6. 9 13(2) 7. 9 13(2) 8. 3 14(1) 9. 7 15(1) to include all training received including induction and foundation. This requirement is restated from the last inspection. Timescale for action was 31/7/05. The registered person must ensure that staff receive regular training in areas of mental health that reflect the current service user groups needs. For example schizophrenia and anorexia. This requirement is restated from the last inspection. Timescale for action was 31/7/05. The registered person must ensure that the date of opening of eye drops is always written on the bottle to ensure that they are only used for the correct time after opening. This requirement is restated from the pharmacist visit carried out on the 25/7/05. The registered person must ensure that sufficient space is available on Collingwood and Eastview to enable staff to administer medication in a safe and efficient manner. This requirement is restated from the pharmacist visit carried out on the 25/7/05 The registered person must ensure that the service users who receive respite care are fully assessed to ensure that their needs are fully understood by staff. The registered person must ensure that the service users who receive respite care have completed individual plans in place that include a night time care plan to ensure that care staff understand the service users needs and support 31/10/05 2/9/05 31/10/05 30/9/05 1/10/05 Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 26 10. 9 13(2) 11. 18 13(6) 12. 22 12(1)(3) 13. 27 18(1)(a) 14. 30 18(1) (c )(i) requirements fully. Daily records must include night-time checks. The registered person must ensure that the MAR sheets for service users who have prescribed medication in the form of creams stipulate clearly where, how often and how the cream is to be applied to safeguard service users and staff, reference must be made to the individulal plan for more intimate applications. Agreed guidelines must be in place. The registered person must ensure that the actions agreed during a recent adult protection strategy meeting following a series of complaints received by the placing authority are complied with. The registered person must ensure that response times to the call bell system are suffcient to meet the service users needs. thirty minutes is not an acceptable time for service users to wait for assistance at any time of the day or night. The registered person must ensure that at all times there are sufficent staff who are suitably qualified to meet the needs of service users at night and in the event of a fire. This specifically relates to those service users on the top floor who have dementia care needs. Two additional waking night staff and one care staff must be employed. The registered person must ensure that staff receive training to meet the needs of service users, particularly those who receive respite care such as those with parkinsons or those service users recovering from strokes who do not require 1/10/05 1/10/05 2/9/05 1/11/05 31/12/05 Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 27 nursing care. 15. 38 12(1) The registered person must 1/12/05 promote the health and safety of service users who receive respite care and who require specialist equipement. An O.T must fully assess service users with additional specialist needs for example, the need for chairs with a higher sitting position. This is necessary to ensure that service users have appropriate equipement during their stay. The registered person must 2/9/05 ensure that the actions listed on the fire enforcement notice issued on the 4/7/05 is complied with fully. The fire risk assessment must be reviewed. Two fire doors must be replaced and all fire doors must be kept shut at all times and not propped open under any circumstances. 16. 38 23 (4)(5) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 13 Good Practice Recommendations It is recommended that the registered person research and identify suitable befrienders or volunteers to visit service users on a regular basis. This would promote independence and promote the development of friendships for some service users who sometimes feel lonely. This recommendation is restated from the last inspection. It is recommended that the rota is revised to show clearly the designation of each member of staff and the times shift start and finish particularly for night staff. A clear key should be provided on the rota so that all staff understnd what different colour codes and symbols mean on the rota.This recommendation is restated from the last inspection. It is recommended that the registered person consider providing IT skills training to enable support staff to 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 28 2. 27 3. Merrivale 30 4. 33 update and review individual plans and other documentation related to service users effectively and efficiently.This recommendation is restated from the last inspection. It is recommended that office files are reviewed and organised in such a way to make information more readily availble and accessible to all staff.This recommendation is restated from the last inspection. Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 29 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Merrivale 20050901 Merrivale X00015 UN Stage 4 S10518 V244919 G59.doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!