Care Home: Marian House Nursing Home

What the care home does well The home has a good pre admission system enabling people to visit the home and an assessment is undertaken to ensure that their needs can be met on moving into the home. People living in the home have access to a range of Health and Social Professionals and this ensures that any health care needs are met. Visiting is flexible enabling people to maintain relationships that are important to them. Visitors are made to feel welcome and a good rapport was observed to had built up between people using the service, staff and their visitors. There is a choice of wholesome meals which meet any dietary needs for reasons of health, taste, culture or religion. The environment was homely, clean and well maintained so providing a pleasant place for people to live. They are able to personalise their bedrooms to reflect their individual tastes, age, gender, and culture so that they feel comfortable in their surroundings. Aids and adaptations are provided so that people`s independence is maintained and promoted whilst maintaining their safety. Staff have the appropriate skills and knowledge to work safely and effectively and provide a good standard of care to people living at the home. The home has a comprehensive quality assurance system to determine areas of good practice and areas that need improvement. People living at the home are involved in producing an interesting newsletter. People living at the home are supported to continue to practice their chosen religions either by religious leaders accessing the home or being assisted to attend services outside the home. Medication management was good ensuring people who live at the home receive the correct medication to meet their clinical needs. People who live at the home and other stakeholders are aware of the complaint procedure but also expressed that the management team were approachable and dealt with issues appropriately and sensitively. The home was clean an well maintained and comments from people who live at the home and other stakeholders confirmed that this was the norm. What has improved since the last inspection? There have been a number of areas in the home that have been refurished, making the environment pleasant, hygiene and homely. Care planning and record keeping has improved. Plans are updated to reflect people who live at the homes current need. Recruitment procedures have been reviewed and this also includes people living at the home being involved in the recruitment process, so their opinion is sort as to the potential of a new worker at the home. The management team have revisited the safeguarding procedures and ensured that all staff are aware of this to promote and maintain the well being of people who live at the home. Sluice disinfectors have been fitted which will enhance the infection control procedures in place to protect residents from cross infection. A review of the staffing structure has taken place, with more senior carers working in the home who work alongside carers and nurse to promote the well being of residents. A higher percentage of staff have obtained a NVQ 2 or above in care thus demonstrating a level of recognised skill and competence to meet people who live at the home needs. What the care home could do better: A review of social activities needs to taken place to ensure people who live at the home maintain a fulfilled life. The CSCI registeration certificate needs to be displayed in full to ensure that visitors and people who live at the home are aware of what the home is registered for and who`s needs they can meet. CARE HOMES FOR OLDER PEOPLE Marian House Nursing Home 32 Walmley Ash Road Walmley Sutton Coldfield West Midlands B76 1JA Lead Inspector Karen Thompson Unannounced Inspection 21 August 2008 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 Marian House Nursing Home DS0000024866.V370055.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. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marian House Nursing Home Address 32 Walmley Ash Road Walmley Sutton Coldfield West Midlands B76 1JA 0121 240 8000 0121 240 8039 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) Currently under development Walmley Care Home Limited Miss Josephine Louise Stinton Care Home 41 Category(ies) of Physical disability (41) registration, with number of places Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Physical disability (PD) 41 The maximum number of service users who can be accommodated is: 41 20th August 2007 Date of last inspection Brief Description of the Service: Marian House Nursing Home is privately owned by Walmley Care Homes Limited, and provides 24 hour nursing care for up to 41 older people. It is able to offer care to adults over 50 years of age with a physical disability. It is situated in a residential area of Sutton Coldfield and public transport is easily accessible. Marian House Nursing Home is a purpose built Home with single accommodation on both floors, many of which have en suite facilities. There are ample assisted bathing and toilet facilities and staff are available to provide assistance in these areas as required. There are lounge/dining areas situated on both floors. There is a range of aids and adaptations designed to accommodate residents with limited mobility, such as hoists, grab rails, a passenger lift and nurse call system. The internal and external environment is suitable for wheelchair users. There is off road parking to the front and side of the property and a garden at the rear for residents’ use. There are notice boards located throughout the Home displaying information of interest to residents, visitors and staff. Information about CSCI was on display and a copy of the most recent CSCI report was on display for anyone interested to refer to. The weekly fee to live at Marian House is between £625 and £795 the nursing element care contribution is paid back to people living at the home. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 5 Items not included within this fee include hairdressing, staff escorts for routine medical appointments, chiropody and toiletries. For up to date fee information the public are advised to contact the home. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to plan the inspection, which included notifications received from the home and an Annual Quality Assurance Assessment (AQAA). This is a questionnaire that was completed by the manager and it gave us information about the home, staff, people who live there, any developments since the last inspection and there plans for the future. In addition the home was asked to distribute surveys out to people who live in the home, relatives and health professionals after the inspection visit. Surveys returned to us were positive about the care provided. One health professional commented “service users are well looked after”. One inspector undertook this fieldwork visit carried out over two days. The registered manager and deputy were available for the duration of the inspection. The home did not know were coming on the first day and was not informed of when were would be returning to complete the inspection. At the time of the inspection forty people were living in the home and information was gathered from speaking to and observing people who lived at the home. Two people were “case tracked” and this involves discovering their experiences of living at the home by meeting and observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. At the time of inspection two people who live in the home and four members of staff were spoken to in order to gain comments. What the service does well: Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 7 The home has a good pre admission system enabling people to visit the home and an assessment is undertaken to ensure that their needs can be met on moving into the home. People living in the home have access to a range of Health and Social Professionals and this ensures that any health care needs are met. Visiting is flexible enabling people to maintain relationships that are important to them. Visitors are made to feel welcome and a good rapport was observed to had built up between people using the service, staff and their visitors. There is a choice of wholesome meals which meet any dietary needs for reasons of health, taste, culture or religion. The environment was homely, clean and well maintained so providing a pleasant place for people to live. They are able to personalise their bedrooms to reflect their individual tastes, age, gender, and culture so that they feel comfortable in their surroundings. Aids and adaptations are provided so that people’s independence is maintained and promoted whilst maintaining their safety. Staff have the appropriate skills and knowledge to work safely and effectively and provide a good standard of care to people living at the home. The home has a comprehensive quality assurance system to determine areas of good practice and areas that need improvement. People living at the home are involved in producing an interesting newsletter. People living at the home are supported to continue to practice their chosen religions either by religious leaders accessing the home or being assisted to attend services outside the home. Medication management was good ensuring people who live at the home receive the correct medication to meet their clinical needs. People who live at the home and other stakeholders are aware of the complaint procedure but also expressed that the management team were approachable and dealt with issues appropriately and sensitively. The home was clean an well maintained and comments from people who live at the home and other stakeholders confirmed that this was the norm. What has improved since the last inspection? Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 8 There have been a number of areas in the home that have been refurished, making the environment pleasant, hygiene and homely. Care planning and record keeping has improved. Plans are updated to reflect people who live at the homes current need. Recruitment procedures have been reviewed and this also includes people living at the home being involved in the recruitment process, so their opinion is sort as to the potential of a new worker at the home. The management team have revisited the safeguarding procedures and ensured that all staff are aware of this to promote and maintain the well being of people who live at the home. Sluice disinfectors have been fitted which will enhance the infection control procedures in place to protect residents from cross infection. A review of the staffing structure has taken place, with more senior carers working in the home who work alongside carers and nurse to promote the well being of residents. A higher percentage of staff have obtained a NVQ 2 or above in care thus demonstrating a level of recognised skill and competence to meet people who live at the home needs. 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. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 9 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 Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1.3.4 Quality in this outcome area is good Information is available for people so that they can make an informed decision about moving into the home. People’s needs are assessed before they move in, so they can be confident their needs will be met upon moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a service user guide, which was available on entering the home and each person has a copy in their bedrooms. This document provides information about the services and facilities provided and enables people to make an informed choice about moving into the home. The home was displaying its current registeration certificate but was advised they need to display both pages of the certificate. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 11 The home provides care for people who require long term nursing care. People are encouraged to visit the home before moving in to view facilities, meet staff and other people who live there in order to sample what it would be like to live there. The management team are reviewing how they will record these day visits to enable them to enhance the service for people who live at the home. We were informed that the home has a waiting list, so people are contacted by the home when a bedroom becomes available to see if they still wish to live at Marion house. If a person still wishes to move into the home a comprehensive assessment is carried out by the home to determine whether they can meet that person needs. Following this assessment the assessment the management team send a letter to the person who wishes to move into the home or their family confirming that care needs could be met living at the home. The records of one person who had moved into the home recently were found to have been completed to the required standard. Relatives were observed visiting the home on the first day of the inspection visit and shown the various facilities and informed of what the admission process would entail, if they like the home and felt it was appropriate to their relative. Intermediate care is not provided at Marian House nursing home. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is excellent. There are good systems in place to ensure people’s health and personal care needs are met in a way that ensures peoples dignity is maintained. The medication system is well managed ensuring people receive medication prescribed and ensuring their safety and well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person living in the home had a care plan. This is a document that is developed by staff following an assessment of individual needs. It outlines what they can do and the support they require to be given by staff in order to meet their needs. Three peoples care files were looked at in detail. Care records also contained risk assessments in respect of areas such as pressure sore risk, manual handling, falls, use of bedrails and nutrition. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 13 One person was assessed as being at high risk of developing pressure sores, their care plan had a list of instructions to prevent this occurring, this included an appropriate mattress and ensuring the person position was changed on a regular basis. The mattress was observed to be on the person bed and staff were recording on a regular basis when a change of position had taken place. Nutritional risk assessments were in place for people living at the home, but these were not always leading to specific care planning instructions to demonstrate how were to be meet. Bedrail risk assessment were in place, the management team were unsure of the source of the assessment and whether this had been based on any evidenced research. The management team did however state they would review this risk assessment. Manual handling risk assessments were in place and a variety of equipment was available to meet the assessed needs of people living at the home. Care planning on the whole was good with nice individual details, demonstrating a holistic and personal approach to meeting peoples needs. People who live in the home have access to a range of Health and Social Care professionals. Care records contained detailed information of visits from these professionals and outcomes. Medication management with in the home was good. The medication room was observed to be locked and the Medication trolley was secured to the wall in this room when not in use. The medication trolleys were clean and tidy therefore allowing for easy of access to find drugs. The medication system consisted of a blister and box system with printed Medication Administeration Record (MAR) sheets being supplied by a dispensing pharmacist. The home has copies of the orginal prescription (FP10s) so they were able to check the prescribed medication against the MAR chart when it entered the home. People can self medicate once a risk assessment has been carried out, all bedrooms have a lockable facility to allow this to happen. A small random audit of mediations was carried out by us and these were found to be correct. The home carry’s out it own medication audits to identify any concerns or errors quickly The Deputy Manager co-ordinates the medication management. Staff knowledge in relation to medication was good. The home has established good links with the local hospice and could demonstrate a proactive approach to meeting the needs of people who requires such care. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this outcome area is good. People who live at the home can exercise chose and control over their lives so they experience a meaningful lifestyle. There is a choice of healthy meals that meets the dietary needs of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Visiting was flexible enabling people to visit at a time that suited them so that people living at the home can maintain contact with family and friends however visitors are asked to avoided lunchtimes if possible. Family and friends however can stay for meals if they give the home some notice. The management team informed us that families are invited to come and spend Christmas with their relative in the home if they wanted to . There was no evidence of rigid rules or routines in the home and people who liver there can go outside on their own or with friends and family as they choose, depending on their ability. One person living at the home uses the Ring and Ride Service to leave the home on a regular basis to maintain contact with friends living in the community. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 15 The home has strong links with a local parish church and people living at the home can and do attend the church services and social events associated with this particular church. A Roman Catholic priest was also observed visiting the home at the time of the inspection. At the time of the inspection the home was in the progress awaiting the commencement of an activities co-ordinator. The management team acknowledge that the one area they felt need further improvement was in relation to activities. The management team informed us that people living at the home had been asked to submit ideas as to the activities they wanted once a new activities co-ordinator was in place. A varied and nutritious diet is provided on a flexible weekly rotated menu and people are able to choose their meal and where they want to eat it. Specialist diets are catered for which included pureed, diabetic and high calorie diets. Comments received about food were positive such as “Food here is on the whole very good”. Food moulds are used to present food that needs to be pureed thus enhancing the presentation. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area isexcellent. There are appropriate systems in place so that people are protected from harm. People living at the home are confident their views are listened to and action taken where appropriate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Neither the home or the Commission has received any formal complaints about the service provided since the previous inspection. The home has a comprehensive system in place for dealing with concerns by those who live at the home. The Service Users Guide was available in bedrooms of people who live in the home contained copy of the complaints procedure. The notice board in the hallway area of the home had a copy of the complaint procedure in large print. All ten relatives and five people living at the home who returned surveys to us stated they knew how to make a complaint. One person living at the home stated “Speak to Jo/Joy if they are not here I would speak to the nurses” and a relative “they listen to people” Therefore demonstrating relatives and people living in the home were being given the information to raise concerns and felt happy to do so. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 17 Staff meeting minutes demonstrated that staff had been remind recently about the complaints, safeguarding and whistle blowing procedure. Staff have received formal training in safeguarding. The adult protection policy included local multi-agency guidelines and staff meet during the inspection had a good knowledge of this. Staff surveys returned demonstrated that staff felt supported in caring for and meeting the needs of people who live at the home. A compliments and thank you folder was available in the reception are of the home. The manager stated that the majority of staff have received training in relation to Mental Capacity Act and they had a copy of the Department of Health training set in relation to Mental Capacity. Also a booklet was available advising how to contact the Independent Mental Capacity Adocate (IMCA) the manager stated that this had also been given to all staff working at the home. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.24.26 Quality in this outcome area is good. People live in a homely, comfortable and well maintained environment where they feel safe and secure and their privacy is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The external appearance of the home is attractive and well maintained. There is a secure garden at the rear of the home that is accessed via a ramp and is suitable for wheelchair users. The reception area of the home is welcoming and homely in appearance. There is a CCTV intercom system installed on the front door so that staff should be aware of who is entering. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 19 Residents have a choice of lounges in which to spend their time and a quiet room is available for people who live at the home to meet with their visitors and hold private celebrations if they wish. There is a spacious separate dining room and this is a pleasant area in which people who live at the home can eat their meal. Communal areas are decorated to a high standard in the main, in summon of the communal toilet areas, the plaster work was observed to be lifting away from the wall. We were informed that this was an issue they were aware of and were trying to resolve. People who live at the home have a choice of assisted bathing and shower facilities. One bath has recently been replaced we were informed that this was done in consultation with an occupational theraphist to ensure the facility meet the needs of people living at the home. The home was clean and both people who live at the home and relatives who returned surveys commented on the cleanliness of the home and the high standard that is maintained throughout the premises. Aids and adaptations were available though out the home including raised toilet seats and handrails in corridors and near to toilets. All bedrooms were for single occupancy, some with en suite facility. All bedrooms were personalised to reflect the tastes and interests of individuals and providing a home from home environment. A call bell facility was available in each bedroom to call for assistance if required. Two mechanical sluice disinfectors have been purchased for use in the home, these had been installed but were not operational at the time of the visit as they were awaiting final installation. Once operational this will promote greater protection for people and staff living and working at the home from spread of infection. Staff were observed to be thoroughly cleaning equipment in the home. The deputy manager advised us that set procedure are in place to promote and prevent cross infection and this was an active part of the staffs role. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 Quality in this outcome area is good. People are supported by staff who are in the main trained and have the knowledge and skills to meet their needs effectively. There is a robust recruitment system on employing new staff for the protection of people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection there were satisfactory numbers of staff on duty to meet peoples needs. The duty rota indicated that there was a least two trained nurse throughout the day with at six care staff on duty of a morning and five care staff of an afternoon. Night cover consisted of one trained nurse and three care staff. In addition to this there are domestic and catering staff. The manager for the majority of shifts is roster as supernumary. There is a stable group of staff with a low staff turnover, which provides continuity of care to people living at the home. The management informed us that they had increased the number of senior carers available and working in the home from two to five. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Record Bureau checks had been made and written references received. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 21 The manager has asked people living at the home whether they wanted to be involved in the recruitment process. One person living at the home has been involved in the process of meeting candidates being interviewed by the management team, they declined to be fully involved, but their opinion was sort. This enables people living at the home to have some control over who works in their home. Following recruitment of new staff the home undertakes an induction training programme. One staff member stated about their induction “ It was very helpful because every thing new for me and I need to learn about all routines and equipment.” and they went on further to state “my manager gave me the opportunity to attend as much as training seminars to keep up and learn new ways of working its very helpful and I learnt a lot.” There is a rolling programme of basic training which includes, fire safety, manual handling, health and safety, food hygiene etc. The Registered Manager is providing manual handling training at present for staff. Records indicate that over eighty percent of care staff had completed NVQ 2 training or above in care. This training improves staff knowledge and skill and leads to improved outcomes for people living in the home. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. The home is well managed and run in the best interests of people living there. Systems are in place to ensure the health, safety and protection of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management team consist of the registered manager, deputy manager and administrator. Each member of the management team had delegated responsibilities and it was apparent that they were enthusiastic and striving to improve the quality of lives of people living at the home. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 23 The management office was located at the front of the building near to the front entrance and this provides the opportunity for people living in the home and visitors to access them easily as there was an open door policy and this was observed during the inspection. Two staff informed us enthusiastic about working in the home. One stated “haven’t regretted a day of it……always look forward to coming, all staff nice, all very approachable, very supportive…..residents are lovely but every one is different which is how it should be” . The other staff member stated “good atmosphere, good training, good staff, always learning….good team spirit, the new staff have the option to carry on working with trained nurse”. Staff who are happy in their work promote a happy environment with in the home for people living there. This is being achieved by a number of measures good recruitment practice, training and supervision. Meeting with people living in the home and staff take place regularly. There is a robust quality assurance system in place. Outstanding requirement have been actioned. Comments received from people who live at the home, relative, health professionals and staff were positive about the home. Supervision takes place for staff on a regular basis and looks at core skills and training development needs. Staff also under go competence checks to ensure their skill are up to date. Staff were able to demonstrate an awareness of equality and diversity issues. Prior to the inspection an Annual Quality Assurance Assessment was completed. The document gave us all the information we asked for and was returned in a timely manner. The administrator stated that the home holds no money for residents. Relatives are invoiced if the home incurs any expenses on the residents behalf such as hairdressing. A sample of records in relation to servicing and checking of equipment were inspected to determine health and safety systems in the home and they were found to be up to date e.g. Gas safety certificate, fire equipment, lift, PAT testing and electrical hardwiring. Checks were made on hot water outlets to ensure it is maintained at as satisfactory temperature to prevent scalding. Clinical procedures were available for staff. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 24 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 2 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 4 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 x x 3 x 3 Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation Care Standards Act Requirement All of the current registration certificate must be displayed so that people who use and visit the home are aware of what the service can provide. Timescale for action 21/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 26 No. 1 2 Refer to Standard OP12 OP8 Good Practice Recommendations The home should review the provision of activities with in the home and how these are to be provided. Nutritional risk assessments to be linked into the care planning process so the effectiveness of care can be monitored. Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Marian House Nursing Home DS0000024866.V370055.R01.S.doc Version 5.2 Page 28 - 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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