Inspection on 02/03/07 for Merrivale

This inspection was carried out on 2nd March 2007.

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

The inspector 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 26/04/06

Merrivale 01/09/05

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 Jane Ray Key Unannounced Inspection 2nd March 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Merrivale DS0000010518.V323153.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. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Merrivale Address 90 East Road Burnt Oak Middlesex HA8 0BT 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) 020 8952 7639 020 8951 5310 Manager.winglodge@fremantletrust.org The Fremantle Trust Miss Gillian Frances Smith Care Home 56 Category(ies) of Dementia - over 65 years of age (56), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (56), Old age, not falling within any other category (56) Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th April 2006 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. 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. Plans are advancing for the home to be totally rebuilt on a site adjacent to the existing home and it is anticipated that this will be complete by the end of 2007. On the day of the inspection there were 46 service users and two long-stay and eight respite available beds, although referrals were being processed. The current fees are £492 per service user a week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 2 March 2007 and was unannounced. This inspection was the second annual key inspection and all the core standards were inspected. The inspection also checked how the service was progressing in meeting the requirements from the previous inspection that had taken place on the 25 September 2006. The inspection took seven hours to complete. The inspector focused on three long-stay units, for older people and people with dementia and people with mental health issues. The inspector interviewed one member of staff in each unit and also spoke to service users individually or in groups in each unit. The manager and other senior staff assisted with the inspection. The care records, staff records and health and safety records were also inspected. The Service Manager who is the home managers line manager also joined the inspection for part of the day. What the service does well: Many of the service users and their relatives were full of praise about their lives at Merrivale and the care they receive from the staff. The individual staff were observed to be providing a high standard of personal care. The staff were very positive about their work and when they spoke to the service users they demonstrated a good knowledge of their individual needs and a caring approach. The home was clean, tidy and homely throughout. The lunch that was served during the inspection was tasty and nutritious and where it needed to be pureed this was done separately in an appropriate manner. The care plans and risk assessments were up to date and reflected the needs of the service users. They also demonstrated close working with other healthcare professionals when this is needed by the service users. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Eighteen requirements and one recommendation have been made at this inspection of which seven are immediate requirements and one is an enforcement notice. A requirement was made under the heading choice of home for the staff to all receive the training to enable them to meet the specific needs of the service users including understanding how to support people who have Parkinsons disease, have had a stroke or have a mental illness. Five requirements were made under the heading health and personal care. These were to ensure each service user is supported to have an annual review meeting with their care manager and relatives. They also need to be supported to have a dental check and to have their weight checked regularly. The medication administration sheets must be fully completed with no gaps and creams must have clear instructions for staff about where they need to be applied. A requirement was made in the daily life and social activities section to ensure that a full time activity co-ordinator is provided to ensure all the service users have access to a range of stimulating activities suitable to meet their individual needs. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 7 A requirement was made under the heading of complaints and protection to ensure that training dates are arranged to ensure all the staff receive training on the protection of vulnerable adults. In the section on staffing five requirements were made. The first is to ensure there are adequate numbers of staff on duty throughout the day in all of the units. There are serious concerns about low staffing levels at certain times of the day and this has resulted in enforcement action. Secondly the home needs to prepare a recruitment programme to fill the vacant staff hours. Staff also need to be available to carry out reception duties in the home. A programme with timescales needs to be available to ensure adequate numbers of staff undertake NVQ training in care and all the staff need to complete their induction. Five requirements were made in the section called management and administration of the home. One was to write up the results of the annual quality assurance exercise to ensure the action plan is being implemented. Secondly the staff need to be supported to have regular individual supervision. From a health and safety perspective the home needs a fire safety emergency plan and night time fire drills, to have the annual gas safety check and to have the electrical installation check completed. 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. Merrivale DS0000010518.V323153.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 Merrivale DS0000010518.V323153.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be assessed prior to their admission to ensure the home can meet their needs and this assessment will be reviewed and updated throughout their stay in the home. They will also be offered a contract between the home and the service user. Staff need to receive additional training to ensure they can meet the specialist needs of the service users. EVIDENCE: Four service user case notes were inspected to see if they had a contract available between themselves and the home. They all had contracts and these included appropriate information about the fees and had been signed. Four service user case notes were looked at in three separate units in the home. They all contained an assessment prepared by the social services Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 10 department and an assessment prepared by the home covering all the main areas of need. The inspector could see that these assessments had been updated to reflect the changing needs of the service users. The service users at Merrivale have a wide range of individual needs due to the services offered in the different units. The staff work across the different units and therefore need to be familiar with the different service user needs. Areas for training include caring for people with dementia, mental health issues and physical care issues including strokes and Parkinsons disease. The staff training records were inspected for six staff who have been in post for at least a year. Three had received training on dementia, two had received training on mental health and none had a record of receiving training on either Parkinsons disease or strokes. The manager explained that further training was planned on dementia but dates were not available for training on mental health, Parkinsons disease or strokes. The home does not provide an intermediate care service and so this core standard has not been inspected. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are receiving a high standard of personal care. They are also being supported to have their healthcare needs met, although they still have not had dental checks. Service users are protected by improved medication systems in the home but there are still occasional gaps in the administration records. EVIDENCE: Four care plans were inspected in three units. The care plans are based on the identified needs from the assessments. They clearly record what support each service user needs from the care staff. The care plans also include a night care plan. Each service user also has a risk assessment. Most have a moving and handling assessment and other risk assessments are also available if required. The care plans and risk assessments have been reviewed on a monthly basis for the long stay service users. Only two of the four long stay service users had a record of an annual care plan review meeting with their care manager and Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 12 relatives and the manager explained that the home is currently in the process of bringing these reviews up to date. The service user case notes were well organised and easy to follow. Daily reports are also completed for each service user. The health care records were inspected for four service users. There is a clear record, of the healthcare input received by each service user and these reflected their individual needs and demonstrated close working with other care professionals. None of the service users had a record of having a dental check. The manager explained that they had identified a dentist who could provide a service but appointments had not yet been made. The service users had Waterlow risk assessments and nutritional risk assessments to monitor if they could be at risk of developing a pressure sore. In addition the records showed that service users are having their weight checked on a monthly basis, although one of the four service users had not had their weight checked for the past six months. The manager explained that at the time of the inspection none of the service users had a pressure sore. The medication was inspected in three units. The long stay units use the Boots blister pack system. All the units keep a record of medication arriving in the service and returned to the pharmacist so it is possible to have an audit trail of the medication. Two staff sign for control drugs when they are being administered and a record of this is held in a book kept in the main office. The temperatures are recorded daily in all the medication cupboards. The senior staff check the administration records on a daily basis and this had improved the accuracy of the records. There was however a gap found in two service user medication records on Collingwood unit and one on Cara unit. In two of the three units inspected, cream was being administered to service users and there were clear directions on how this should be applied but on Mapleview unit the medication administration records just say to give “as directed”. The home has an up to date record of which staff can administer medication with sample signatures. A copy of this record is available on all of the units. Throughout the inspection the inspector observed that the staff were supporting the service users to receive care and support in a manner that respected their privacy and dignity at all the times. Service users who spoke to the inspector said they found the staff were very kind and helpful. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users will be supported to enjoy a healthy and nutritious diet that meets their individual needs. Additional staffing is required to support the service users to enjoy stimulating activities both within and outside the home. EVIDENCE: During the inspection the inspector was not able to see activities taking place. On the mainstream unit the service users were able to tell the inspector that the activity co-ordinator occasionally comes to the unit to do activities with them. On the unit for people with mental health issues one service user said she liked to go out and would welcome more support to achieve this and relatives said they would like their family member to be supported to occasionally enjoy a community trip. On the unit for people with dementia the staff said they would like to see more activities for people with dementia. Since April 2006 the hours worked by the homes activity co-ordinator have reduced from 32 to 23 hours a week. The inspector is of the opinion that a full-time Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 14 activity co-ordinator is needed to effectively deliver activities in a home of this size. It was observed during the inspection that the routines in the home are flexible and based around the needs of the individuals. Service users were observed making choices about what they wanted to eat or drink, whether they spent time in their rooms or the lounge and how they wanted the staff to support them. The manager explained that a local church comes to the home to conduct services on a weekly basis and Catholic service users receive individual visits from the priest if they wished this to take place. The staff and service users explained that visitors are made welcome in the home and this was reflected in comments from one relative who said he felt warmly received when he visited the home. The manager explained that they have still not been able to attract volunteers to work in the home. The inspector spoke to service users about food in the home. They all said that they mainly enjoyed the meals. The home follows a four-week rolling menu and this was inspected and was nutritious. There is always a choice of a main meal and a vegetarian option is also available. Each unit has a small kitchen and prepares breakfast so there is flexibility about when the service users choose to eat. There are also snacks and fruit available in each unit. The food hygiene certificates were inspected for the cook, assistant cook and kitchen assistant and they had all had their food hygiene training updated. During the inspection lunch was served and the staff were observed assisting the service users in a slow and discreet manner, sitting with them. The lunch also took place in a relaxed manner and was seen as a social activity. The needs of service users who required a pureed diet were appropriately met. The inspector also observed in all the units that drinks and snacks were offered throughout the day. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users can be assured that if they make a complaint that this will be addressed in an appropriate and timely manner. Staff have not all received training on the protection of vulnerable adults and ongoing training dates are not yet available. This does not afford an appropriate level of protection to the service users living in the home. EVIDENCE: The service users in three units were asked if they felt able to complain. They all said that they felt able to express any concerns with the staff working in their units or one of the senior staff. The record of complaints and compliments was inspected. It was positive to note that verbal as well as written complaints had been recorded and there was a record of how the issues raised had been addressed and the timescale for the response to be given. One complaint had not been fully addressed within a 28 day timescale but the manager explained that this was because she had needed to wait for supplementary information from the hospital before responding. Since the last inspection there has been one adult protection issue reported by the home using the local adult protection procedure. This was partly substantiated but demonstrated that the home knew how to use the adult protection procedure jointly with social services and CSCI. It did however raise Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 16 concerns about staffing levels in the home and the level of supervision available to protect service users. The staff training records were inspected for six staff who had been in post for at least a year and only three had received training on the protection of vulnerable adults. Dates for further training sessions to meet this shortfall were not available in the home. Merrivale DS0000010518.V323153.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users live in an environment that is clean and maintained to a reasonable standard. Whilst some areas of the building would benefit from improvements the inspector recognises that as there are plans for the service to move to a new purpose built unit it is not a good use of resources to undertake this work. EVIDENCE: The inspector did a tour of the communal areas and three units in the premises. The home was clean and there were no unpleasant odours. The home was an appropriate temperature and well lit. Each flat has a comfortable lounge and dining area and these were all bright and appropriately furnished. Throughout the home it was noted that service Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 18 users had been encouraged to bring with them personal items for their rooms. The garden was pleasant and service users can enjoy sitting outside in the warmer weather. The laundry whilst small for a home of this side was operating effectively and all the service users were observed to be wearing clean clothes. The home has a number of doors that operate with special locks to protect service users who may wander. These were all operating effectively. Since the last inspection the home has employed a new maintenance man and he was observed working throughout the home. Merrivale DS0000010518.V323153.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the standard of care provided by the staff working in the home is good this is compromised by unacceptably low staffing levels at various times of the day throughout the home and this could be potentially very unsafe for the service users. Recruitment, whilst undertaken in a thorough manner is very slow and there is still a significant use of agency staff. EVIDENCE: The inspector spoke to staff in three of the nine bedded units who said that at times there is only one member of staff available in the unit. The inspector then sat in the senior carers office during the handover period and saw that this was indeed the case as staff needed to have breaks if they are working a long day or may need to take service users for medical appointments. Freemantle used to employ a member of staff who worked on a floating basis to cover for these eventualities but this post was no longer available. The inspector was very concerned as observation at previous inspections has shown it is very hard for one member of staff to support the service users in a nine bedded unit and could potentially place the service users at risk. There Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 20 has also been an adult protection issue since the previous inspection where a service user was possibly abused by another service user and this highlighted the lack of supervision caused by low staffing levels. There have also been 22 notifiable incidents since the last inspection 5 months ago of which 7 are accidents leading to fractures or other injuries. This is a high level of injury and may again reflect low staffing levels. The inspector will be taking enforcement action to ensure satisfactory staffing levels in the home. The inspector has also observed that the absence of administrative staff to answer the phone and greet visitors to the home means that the manager and senior care staff use significant amounts of time doing these duties and this is not an effective use of their time. The home is very busy due to the respite and day services that are available and it is required that reception staff are available on weekdays. Since the last inspection the home has continued to recruit staff however the manager explained that there are still approximately 250 vacant staff hours. On the day of the inspection 4 of the staff shifts were being covered by agency staff although these staff work regularly in the home. The requirement to recruit more staff is restated from two previous inspections to ensure adequate numbers of staff come into post. The inspector is concerned about the slow rate of recruitment and has made an immediate requirement for the home to have a clear recruitment programme with timescales for recruitment targets. This needs to be a priority as changing terms and conditions in the home mean that staff turnover may increase. The manager explained that the home has a staff team of approximately 36 care staff. At the time of the inspection four staff had completed an NVQ in care and eight staff were undertaking the qualification. This means that the home does not meet the minimum ratio of 50 staff having completed or undertaking training for an NVQ in care. This is outstanding from two previous inspections and an immediate requirement was given to provide CSCI with a programme and timescale for additional staff to start the training. Four staff recruitment records were inspected for permanent staff who have come into post since the previous inspection. All the staff had confirmation of a CRB disclosure, a copy of ID and visa where necessary. The induction records were checked for the four new members of staff. These inductions had all been started but needed to be progressed further. Since the last inspection the home has prepared a training record for all staff in the form of a matrix and this information has been completed for all the staff. Merrivale DS0000010518.V323153.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a registered manager with the appropriate skills and experience. Staff would benefit from regular supervision to maintain high standards of work. Service users health and safety is potentially placed at risk by some staff not having received all the necessary training, the lack of a fire evacuation plan, the need for a gas safety check and an electrical installation check that has not yet taken place. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 22 EVIDENCE: At the time of the inspection the area manager was able to tell the inspector that a quality assurance exercise seeking the views of the service users, relatives and other care professionals associated with the home had been conducted in the last year but the results of this exercise were still not available in the home, although the manager was aware of the results and these had been incorporated into her personal action plan. The supervision records were inspected for six care staff. They all had a record of being supervised but none had been supported to receive supervision on a regular basis. The staff training records were inspected for six care staff to see if their health and safety training was up to date. Progress with this training had improved since the last inspection. All of the six had received moving and handling training although for two staff this training had taken place over two years ago. Four of the six staff had received infection control training. Five of the six staff had received fire safety training although for one member of staff the training had taken place over two years ago. Three of the six staff had received first aid training. Four of the six staff had received food hygiene training. The manager explained that she does not yet have dates for the staff to complete outstanding health and safety training. Fire safety measures were in place. The fire alarm and extinguishers had been serviced. The fire alarm had been checked weekly and drills taking place every two months. The records do not however show if the fire drills are taking place at night as well as during the day. The fire risk assessment was in place and had been reviewed. An emergency fire plan needs to be prepared. Certificates to confirm the portable electrical appliances had been checked were available. The gas safety check was out of date. The electrical installation check had been arranged but had not yet taken place. Merrivale DS0000010518.V323153.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 3 3 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 3 3 x x x x 3 3 STAFFING Standard No Score 27 1 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x x 1 x 1 Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 18(1)(c) Requirement The registered person must book training dates to ensure all staff have received training on the specific needs of the service users including mental health, strokes and Parkinsons disease. This is an amended immediate requirement. Previous timescales of 31/10/05, 31/07/06 and 27/09/06 were not met. The registered person must ensure that all the service users are supported to have an annual review meeting with their care manager and relatives. The registered person must ensure that the service users are supported to have dates booked for dental checks and if the service user does not wish to attend the appointment then this is recorded in their case notes. This requirement is amended and is an immediate requirement at this inspection. Previous timescale of 15/05/06 and 31/10/06 was not met. DS0000010518.V323153.R01.S.doc Timescale for action 07/03/07 2. OP7 15(2)(b) 31/05/07 3. OP8 13(1)(b) 07/03/07 Merrivale Version 5.2 Page 25 4. OP8 12(1)(a) 5. OP9 13(2) 6. OP9 13(2) 7. OP12 16(2)(n) 8. OP18 13(6) 9. OP27 18(1)(a) The registered person must ensure the service users are supported to have their weight checked on a regular basis. The registered person must ensure that the medication administration records are fully completed and that there are no gaps. This requirement is restated. Previous timescales of 15/05/06 and 15/10/06 were not met. 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 the service users and staff. This requirement is restated. Previous timescales of 1/10/05, 15/05/06 and 15/10/06 were not met. The registered person must provide a timescale for the recruitment of a full-time activity co-ordinator to ensure that activities are provided that meet the specific needs of people within the service. This requirement is amended and is an immediate requirement at this inspection. Previous timescales of 31/07/06 and 31/10/06 were not met. The registered person must book training dates to ensure that all staff have received adult protection training. This is an amended immediate requirement. Previous timescales of 31/07/06 and 27/09/06 were not met. The registered person must prepare a programme with timescales to recruit staff and fill the vacant staff hours. This DS0000010518.V323153.R01.S.doc 30/04/07 31/03/07 31/03/07 07/03/07 07/03/07 07/03/07 Merrivale Version 5.2 Page 26 10. OP27 18(1)(a) 11. OP27 18(1)(a) 12. OP28 18(1)(c) 13. OP30 18(1)(c) 14. OP33 24(1)-(3) requirement is amended and is an immediate requirement at this inspection. Previous timescales of 1/10/05,30/06/06 and 31/10/07 were not fully met. The registered person must employ reception staff for the home to answer the phone and greet visitors. The registered person must ensure there are a minimum of 2 staff at all times during the day on the 9 bedded units and 1 staff on the 5 bedded units. This is to ensure there are adequate numbers of staff working on the units to ensure safe care practice. This was an immediate requirement at the last inspection and enforcement action is being taken at this inspection. The registered person must provide a programme with clear timescales to ensure that adequate numbers of staff are enrolled for an NVQ so that a minimum of 50 staff have started to study for the NVQ level 2 in care. This requirement is amended and restated and is an immediate requirement at this inspection. Previous timescales of 30/08/06 and 15/11/06 were not met. The registered person must ensure that all the new staff are supported to complete their induction training. The registered person must ensure that a copy of the results of the quality assurance exercise are available in the home and that an action plan is available. This requirement is restated. Previous timescales of DS0000010518.V323153.R01.S.doc 30/04/07 31/03/07 07/03/07 30/04/07 07/03/07 Merrivale Version 5.2 Page 27 15. OP36 18(2) 16. OP38 13(4) 17. OP38 23(4) 18. OP38 13(4)(a) 31/05/06 and 31/10/06 were not met. The registered person must prepare a programme of supervision to ensure that all staff receive regular individual supervision and a record of this is placed in their supervision records file. This requirement is restated and is an immediate requirement at this inspection. Previous timescales of the 31/05/06 and 31/10/06 were not met. The registered person must ensure the electrical installations have a current maintenance certificate and no remedial work is outstanding. This requirement is amended and restated. Previous timescales of 15/05/06 and 15/10/06 were not met. The registered person must prepare a fire safety emergency plan and to ensure that fire drills take place at night. The registered person must provide a completed annual gas safety maintenance check. 07/03/07 31/05/07 30/04/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP13 Good Practice Recommendations The registered person should work with local community groups to look at ways of encouraging volunteers and befrienders to come to the home. Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Merrivale DS0000010518.V323153.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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