Care Home: Marsden Heights Care Home

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What the care home does well What has improved since the last inspection? This was the first inspection following the change of owners. What the care home could do better: New residents should have their `temporary` care plans developed with them as soon as possible, to make sure all their needs are carefully considered and staff are properly instructed. To help make sure the residents receive more personalised care, the new care plan format should be introduced for all residents as soon as possible. Care plans should continue to be developed with the involvement of the residents, to ensure all their needs and wishes are known and planned for. Some instructions for staff about `when necessary` and `variable dose` medication, needed further clarity to ensure people living at Marsden Heights are properly supported. To make sure people are properly and safely supported with their medication, the home needs to make sure staff have suitable guidance on `covert` use of medication.To help make sure any complaints are properly investigated and managed, ways of assisting with this process should be introduced. So that staff can have easily find guidance when needed, all safeguarding policies and procedures should be combined together. To show improvements in the home are ongoing, plans should be made indicating what is to be upgraded and when. CARE HOMES FOR OLDER PEOPLE Marsden Heights Care Home 316 Kings Causeway Brierfield Nelson Lancashire BB9 0EY Lead Inspector Mr Jeff Pearson Unannounced Inspection 14th May 2008 09:00 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 Marsden Heights Care Home DS0000070775.V359310.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. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marsden Heights Care Home Address 316 Kings Causeway Brierfield Nelson Lancashire BB9 0EY 01282 697144 01282 692281 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) Marsden Healthcare Ltd Mark Taylor Care Home 20 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (20) of places Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. Dementia - Code DE (maximum number of places: 3) The maximum number of people who can be accommodated is: 20 Date of last inspection 15/08/07 Brief Description of the Service: Marsden Heights is a detached residence located in a semi rural area on the outskirts of Brierfield. The property is set in its own grounds, with far reaching views from the rear of the home. There is a small car parking area to the front of the home. The home is registered to provide personal care and accommodation for 20 older people and 3 older people with dementia. The residents’ accommodation is single storey; there is a large lounge/dining room and a small ‘quiet’ lounge. There is a veranda to the rear of the home. There are 18 single bedrooms and 1 twin bedroom with an en-suite toilet. Various aids and adaptations are provided including handrails and grab rails and assisted bathing facilities. Staff are available to provide assistance with personal care and support 24 hours a day. The home had a Statement of Purpose and Service User Guide providing information about the care and services available. This information, which should help people make an informed choice about moving into Marsden Heights, was available in the homes entrance hallway. At the time of this inspection visit, the range of fees charged were between £366.00 and £412.00 per week, there were additional charges for hairdressing, chiropody and some toiletries. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people using this service experience good quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Marsden Heights on the 14th May 2008. The visit took 8½ hours and was carried out by one inspector. The residents, their relatives and staff were invited to complete surveys, to tell the Commission what they think about the care service provide at Marsden Heights, some were received at the Commission. Prior to the site visit, the registered person was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of two people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with the residents, registered manager, senior care staff and cook. Various documents, including policies, procedures and records were looked at. Some parts of the home were viewed. What the service does well: The home was being run by a team of staff; who were keen to provide a good service for the residents. One relative made the following comment “I cannot speak highly enough of Mark and his team for the support they give to mum, and the happiness they have given. I am just grateful for the genuine care they provide and the happiness they generate within the home” People were getting attention for health care needs, on resident said “I get the GP and District Nurse whenever needed”. One relative comment was “They are exceptionally efficient at informing us of hospital visits GP visits etc, they discuss the situation beforehand, make arrangements for visits then contact us to discuss the outcome” The residents personal privacy needs were being dealt with sensitively and they were being treated with respect and as individuals. Residents said, “Yes I Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 6 would say I am treated with respect, the staff are very good like that” and “They are nice to me” and “we all get on” Most people were happy with the arrangements for activities and daily routines were fairly flexible “I am really happy here” said on resident, others made comments such as “I enjoy dominoes” and “I really enjoy karaoke, when everyone joins in”. Residents meetings were being held to give people the opportunity to make comments and suggestions. Most people liked the food at Marsden Heights one saying “The food is very good, we can choose whatever we like” and “We get two choices – some have bacon and eggs every morning!” To make sure the residents were being well cared for, staff training and development was being given high priority. Various training courses had been arranged. Positive comments were made about the staff team, residents described them as helpful, kind and nice. Relatives wrote the following comments about the staff team; “They are very caring and efficient, easy to talk to” and “I believe they are examples in the care and dedication they give their residents” What has improved since the last inspection? What they could do better: New residents should have their ‘temporary’ care plans developed with them as soon as possible, to make sure all their needs are carefully considered and staff are properly instructed. To help make sure the residents receive more personalised care, the new care plan format should be introduced for all residents as soon as possible. Care plans should continue to be developed with the involvement of the residents, to ensure all their needs and wishes are known and planned for. Some instructions for staff about ‘when necessary’ and ‘variable dose’ medication, needed further clarity to ensure people living at Marsden Heights are properly supported. To make sure people are properly and safely supported with their medication, the home needs to make sure staff have suitable guidance on ‘covert’ use of medication. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 7 To help make sure any complaints are properly investigated and managed, ways of assisting with this process should be introduced. So that staff can have easily find guidance when needed, all safeguarding policies and procedures should be combined together. To show improvements in the home are ongoing, plans should be made indicating what is to be upgraded and when. 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. Marsden Heights Care Home DS0000070775.V359310.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 Marsden Heights Care Home DS0000070775.V359310.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): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process helped ensure peoples’ needs and wishes, were considered and planned for before they moved into the home. EVIDENCE: The manager explained the usual assessment process involving gathering information and visiting people in their own environment. He said people were now being written to following assessment, to confirm if the home could meet their needs. People were being offered an initial four-week trial period. Records seen showed information had been obtained from Social Services as appropriate. The home had also completed an assessment, taking into consideration peoples individual needs abilities and wishes in matters such as personal care, bathing, dressing, continence, feeding mobility, social needs, psychological, friends, relatives, hobbies interests, pets and religion. Following Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 10 the assessment an initial care plan had been devised. The cook said she was made aware of peoples’ food preferences and special diets before they moved into the home. The AQAA (Annual Quality Assurance Assessment) completed by the manager and owners, indicated managing emergency admissions as an area for improvement. Residents completing surveys indicated they had received enough information about the home before moving in, one person wrote “I was happy with the information received” The homes guide and statement of purpose had been updated to reflect the change of ownership at Marsden Heights, all residents had been given copies of this revised information. The AQAA completed by the manager and owners, indicated they were to survey residents to see if the new Information Pack was useful. At the time of this inspection Marsden Heights did not provide intermediate care. Marsden Heights Care Home DS0000070775.V359310.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): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most arrangements for responding to peoples’ health and personal care, helped ensure people’s needs are properly and sensitively met. EVIDENCE: Residents spoken with were satisfied with care and attention they received at Marsden Heights. This response was also reflected within surveys completed by residents and their relatives. Residents indicating they always get the care and support they need. One relative wrote, “They are very caring and efficient” The manager explained a new care plan format had recently been developed; this had yet been introduced for all the residents. The format made provision for peoples’ individual needs to be identified over a wide range of relevant matters, such as mobility, sensory and social needs. The wording in the plan was directed to the resident, which made it very person centred. Advice was Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 12 given in ensuring the plan includes clear actions for staff to follow and for short term changes to be noted. Existing care plans seen were still lacking in detail and clear instructions for staff to follow, they had been reviewed but not always properly updated. One person had a been at the home for two months had a ‘temporary’ care plan, this should have been further developed to ensure all needs are properly identified and responded to. The AQAA completed by the manager and owners, indicated that staff training in person centred care planning was to be arranged and that care plans were to be monitored. Health care needs were included with care plans. Records and discussion showed people were getting attention from healthcare professionals such as GP as District Nurses. Residents completing surveys indicated they always receive the medical support needed. Systems were in place to monitor peoples’ weight. Risk assessments were being carried out in relation matters such as, mobility, personal hygiene and bathing. Senior staff had undertaken medication training and further training had been arranged. Medication storage was seen to be secure and clean. The medication records seen appeared accurate, clear and up to date. Individual separate protocols had been devised to provide instructions for when necessary and variable does medication. Some instructions needed further clarity to ensure people are properly supported, for example, the name of topical cream should be included and the specific areas where it is to be applied. The owners were auditing medication systems as part of their visits to the home. The manager said medication policies had been reviewed and updated he agreed to check that ‘covert’ administration had been included. Residents spoken with considered they were treated with dignity and respect. Observations of care practices during the inspection indicated peoples privacy needs were being respected. People had been asked about their preferences on night-time checks. Staff spoken with expressed sensitivity when describing how they support and interact with residents. Marsden Heights Care Home DS0000070775.V359310.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Marsden Heights had opportunities to make choices and decisions about matters affecting them. EVIDENCE: The residents spoken with said they were happy living at the home, “I am quite happy here at Marsden Heights” said one person “I like it because it’s friendly” commented another. Routines seemed flexible, the residents spoken with said they could go to their rooms whenever they wished. It was apparent peoples religious needs were being considered and responded to, Christian services were being held and individuals were being supported to follow their chosen faith. The residents surveys indicated they were mostly happy with the activities available, including dominoes, bingo and skittles, an outing to a safari park had been arranged and an entertainer was due to visit. One staff member explained how some residents had recently enjoyed sitting in the garden listening to music and eating ice creams! Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 14 The homes’ visiting arrangements were included in the homes guide. Residents spoken with indicated they could see people at any time. Relatives indicated in surveys they were made welcome at the home; one commented “I am always made welcome when ever I visit the home…they also invite us to join in with their planned events such as barbecues etc.” Most relatives completing surveys also indicated the home always kept in touch with them. Residents meetings were being held on a regular basis, “they ask us if we have any suggestions” explained one resident. The meetings were being used to involve people in discussing matters such as menus, activities and outings. Most relative completing surveys considered the home always supports people to live their chosen lifestyle. All the residents spoken with expressed an appreciation of the food provided at Marsden Heights, with comments such as “we get some good food, they feed you well here” and “the food is very good, we can choose whatever we like” New summer menus were soon to be introduced; the residents had been consulted about the meals to be included. Specific diets were being catered for and likes and dislikes were known. The dining room provided a pleasant area for the residents to eat their meals, there were fresh flowers on the tables and the days choice menu was displayed. The AQAA completed by the manager and owners, provided a clear indication that activities, outings, responding to spiritual and social needs, also menus and food nutrition to be areas for further development. Marsden Heights Care Home DS0000070775.V359310.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Practices and procedures were effective in responding to complaints and providing safeguards for people using the service. EVIDENCE: Residents spoken with said they had no complaints, but expressed an awareness of the complaints procedure and who to raise any concerns with. They indicated that residents meetings were useful for airing views and opinions. Most relative surveys also showed they were aware of the procedure, one comment made was “Procedures fully explained at the outset. I have never had cause to complain or had concerns about the care home” The complaints procedure was in the home’s guide and displayed in the entrance hallway. A new form had been introduced for making and recording complaints. Records and discussion with the manager showed the last complaint had been satisfactorily dealt with. However, complaint investigations were discussed further, in particular, devising investigation strategies and ensuring systems make proper provision for recording interviews/discussions and all action taken. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 16 Most residents completing surveys indicated they knew who to speak to if they were not happy. Those spoken with indicated they were happy with things at the home and that they would let someone know if they were not “I would tell them if things weren’t right,” said one person. The manager and staff spoken, with expressed a good awareness of safeguarding matters, including the action to be taken in response to any protection issues. Policies and procedures to promote safeguarding of the residents were available, it was suggested these be combined together for easier reference. In house training ad been held and some staff, including the manager had attended external training. There was a clear indication within the AQAA completed by the owners and manager, that safeguarding matters, such as training, developing guidance and care planning was to be improved and further developed. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided the residents with a homely and clean place to live. EVIDENCE: The residents spoken with were satisfied with the accommodation provided at Marsden Heights, most had personalised their bedrooms with their own belongings, which helped create a sense of home and ownership. On resident commented, “We have got new bedding and nice décor” They were also appreciative of the long distance views from the lounge. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 18 Since taking over the home, the new owners had made some improvements, for example new bedding and towels had been obtained and the manager said that work was soon to start on improving the front garden and that additional mobility equipment had been requested for toilets. The standard of decoration and accommodation was satisfactory and furnishings were domestic in appearance. The home was found to be clean and free from unpleasant odours. Satisfactory laundry equipment and facilities were available, designated cleaners were employed at the home. Infection control policies and procedures were available. Although there was a clear indication within the AQAA completed by the owners and manager that the home was to be refurbished and upgraded in several areas. And that they had refurbishment plans to enhance the environment and facilities at Marsden Heights; these plans were not available in the home, which meant we did not have clear assurances of the progress to be made within set timescales. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements, recruitment and training, aimed to ensure the resident’s needs are effectively and safely met. EVIDENCE: Residents spoken with made positive comments about the staff team, describing them as “okay, mostly nice”, and “very helpful”. One person said, “The staff do their work, I like the staff” All the residents’ surveys indicated that they always get the support from staff they need. The staff rota indicated staffing levels were satisfactory. Staffing levels were being kept under review and additional staff were being recruited to ensure a more effective response to covering holidays and sickness. Staff training was being given high priority at Marsden Heights, almost all of the care team had NVQ (National Vocational Qualifications) level 2 or above with one working towards this. Three staff had attained NVQ level 3. Training courses in safe working practices, such as First aid and Moving and Handling, had been arranged and were going. Additional more specialised training had Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 20 been arranged for example, dementia care and Mental Health Capacity Act awareness. Further training had also been planned for. The recruitment records of the two newest employed care staff showed the required information had been obtained and clearance checks carried out. Gaps in employment had been explored and a full employment history requested. It was advised notes be kept of the exploring of any unclear gaps in employment and that applicants be requested to present original training certificates at interview. Staff surveys and discussion confirmed appropriate recruitment practices were being carried out. Records were seen of staff induction training, staff surveys indicated this covered everything needed. New staff were then being supported to undertake NVQ and mandatory training courses. There was an indication within the AQAA completed by the owners and manager that, staffing arrangements and training were being given ongoing attention. Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration practices were effective in ensuring the home is run for the benefit of the residents, staff and visitors. EVIDENCE: The manager has been registered with the Commission since January 2007. He had attained NVQ level 4 in social care management and had completed the Registered Managers Award. He had also received training in medication practices, protection of vulnerable adults, dementia care, moving and handling, Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 22 intermediate hygiene and better food safety. The Manager was being supported by the Director of Marsden Healthcare Limited; who is a registered social worker and has much care experience and relevant qualifications. Regular management meetings were being held. Residents spoken with indicated they were happy with the management of the home, they made comments such as “I feel it has improved” and “It has improved a lot since I first came here” Relatives completing surveys, also made positive comments about the manager and staff at Marsden Heights. Quality assurance was being given significant attention; this had resulted in ensuring that people living in the home are consulted and therefore able to influence changes. People had opportunity to complete surveys; relatives and visiting professionals had also been consulted. Findings of surveys and discussion meetings were being considered and acted upon; results of surveys were displayed in the home. The AQAA (Annual Quality Assurance Survey) completed by the owners and manager, included much detail and identified good practice areas for improvements. It was advised the results/findings of quality surveys be included within the AQAA. The manager said the various methods of fee payment were being discussed during the admission process and were highlighted in the homes’ guide. Systems and practices were in place for managing the resident’s payments of fees. Arrangements were in place for all staff to receive training in safe working practice subjects. The homes AQAA completed by the manager indicated the servicing and checking of equipment and installations. Health and safety policies and procedures were in place; fire safety and environmental risk assessments had been or were being carried out. The last recorded fire drill was 11/06/07, but the manager said two additional drills had been carried out, one as part of training and one in response to a false alarm. These drills needed to be noted in the Fire Records. Marsden Heights Care Home DS0000070775.V359310.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations New residents should have their ‘temporary’ care plans developed with them as soon as possible, to ensure all needs are properly identified and responded to. To promote person centred care, the new care plan format should be introduced for all residents as soon as possible. Care plans should continue to be developed with the involvement of the residents, to ensure all needs and wishes are known and planned for. 2 OP9 Some instructions for staff about ‘when necessary’ and ‘variable dose’ medication, needed further clarity to ensure people are properly supported. To make sure people are properly and safely supported with their medication, action should be taken to ensure Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 25 that staff have suitable guidance on ‘covert’ administration of medication. 3 OP16 To promote accountable and objective complaints investigations, systems should be introduced to ensure investigation strategies are defined and proper provision made for recording interviews/discussions and outcomes. So that staff have easy access to clear guidance, all safeguarding policies and procedures should be combined together. To show improvements to the home are ongoing, a written programme of refurbishment and redecoration, with timescales should be completed. To clearly show gaps in employment have been considered, notes should be kept of explications given. So that relevant qualifications can be confirmed, applicants should be requested to present original training certificates at interview. 4. OP18 5. OP19 6. OP29 Marsden Heights Care Home DS0000070775.V359310.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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