Care Home: Marshview

Similar services:

• Sutton Lodge Nursing Home
• St Helier`s Residential Hotel
• St Joseph`s
• Ridgemount
• Wingham Court
• Old Hastings House
• The Shelley
• Springfield House

What the care home does well Potential new residents benefit from a pre- admission assessment that allows for only those who needs can be met, being admitted to the home. Residents assessed and admitted solely for intermediate care are helped to maximise their independence and return home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects residents privacy and dignity. Residents benefit from an activities calendar that is stimulating and arranged according to their choice. Residents experience mealtimes that are unhurried, whilst all meals are home cooked with an alternative option being available for each mealtime. Residents can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. Residents experience the benefits of a staff team that have the necessary skills and experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of current residents. The management and administration of the home is good, with evidence of consideration being given to residents and/or relatives opinion at all times. What has improved since the last inspection? Pre-admission needs assessments are now completed in full and in consultation with the resident and/or their representative. In order to ensure that all individual health, personal and social care needs are met in a structured and consistent manner, care plans set out in detail the actions which need to be taken by care staff. Care plans are regularly reviewed and updated to accurately reflect resident`s current and changing needs. Suitable risk assessments for falls/tissue viability/nutrition are in place and are also reviewed on a consistent monthly basis. Resident`s are consulted regarding their social and leisure interests and an activities programme has been implemented to reflect those interests and preferences. A review has been carried out in order to enable resident`s to bring in their own furniture. Improvements have been made to ensure that staffing levels are altered according to resident`s current and changing needs. A formal quality monitoring system has now been implemented, which takes into consideration the opinions of resident`s and their relatives. A suitable Fire Risk Assessment, compiled by an authorised person, has been put in place. What the care home could do better: Urgent action was required in order to ensure that the health, safety and welfare of service users is protected at all times, in that the recording of Controlled Drugs entering the home and being administered are to be recorded in a bound, tamper proof book. All bars of soap deemed for communal use are to be removed from bathroom and toilet areas, in order to reduce the risk of spread of infection. Recommendations for good practise have also been made in that all record entries are to be written made in black pen, records of activities attended by residents are to be maintained on a consistent daily basis, advice should be sought from the EHO regarding the safe attachment of the showerhead and the formal quality monitoring system should be expanded upon to include obtaining the views of other stakeholders and interested parties. The results of annual Quality Assurance audits should also be published and made available to all. CARE HOMES FOR OLDER PEOPLE Marshview 77 Marshfoot Lane Hailsham East Sussex BN27 2RB Lead Inspector Rebecca Shewan Unannounced Inspection 09:30 27th May 2008 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 Marshview DS0000021161.V363702.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. Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marshview Address 77 Marshfoot Lane Hailsham East Sussex BN27 2RB 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) 01323 849207 01323 849207 Marshview@beamingmail.com Mrs Maria Mapletoft Mrs Maria Mapletoft Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is seventeen (17). Service users must be older people aged sixty-five (65) years or over on admission. That up to two service users with a dementia-type illness may be accommodated within the total registration of seventeen (17). 6th June 2007 Date of last inspection Brief Description of the Service: Marshview is a large detached two-storey house situated in the market town of Hailsham. It is registered to provide care and accommodation for up to 17 older people. Accommodation comprises eleven single rooms and three double rooms, of which one has en-suite toilet facilities. Nursing care is not provided. The home is situated in a country lane that is within walking distance of local shops and amenities. There are well maintained rear gardens and car parking facilities at the front of the property. All parts of the home are accessible via a stair lift and portable ramps give access to the front of the home and the rear gardens. Grab rails and toilet riser seats are installed throughout the home. There are three assisted baths and all bedrooms have at least a hand washbasin. None of the rooms have full en-suite facilities but there are sufficient communal toilet and bathing facilities to meet residents needs. The range of weekly fees from April 2008, is £365- £480. Additional charges, not included in the fees, include hairdressing (£5), chiropody (£13), newspapers/magazines (varied) and dry cleaning (varied). Potential new residents can obtain information relating to the home by word of mouth, local advertising, CSCI inspection reports, care managers and placing authorities, contacting the home direct and Social Services and the care finder website. Marshview DS0000021161.V363702.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 the people who use this service experience good quality outcomes. This unannounced inspection took place during the morning and afternoon of the 27th May 2008. Incident reports and previous inspection reports, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took six and a half hours. Records such as care plans, staff files and medication records were also viewed. Fifteen service users (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Registered Manager, Senior Carer, four Carers and four were spoken with. The CSCI also conducted Service User and Staff surveys. Of which ten Service User and four Staff surveys were received. The responses from the surveys received were positive in all areas relating to the home and the care provided. Comments received included: ‘We have an excellent cook who prepares very good meals for us’ ‘I am very happy here’ ‘We care for our resident’s well, they are happy and contented, it is a very friendly home.’ What the service does well: Potential new residents benefit from a pre- admission assessment that allows for only those who needs can be met, being admitted to the home. Residents assessed and admitted solely for intermediate care are helped to maximise their independence and return home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects residents privacy and dignity. Residents benefit from an activities calendar that is stimulating and arranged according to their choice. Residents experience mealtimes that are unhurried, Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 6 whilst all meals are home cooked with an alternative option being available for each mealtime. Residents can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. Residents experience the benefits of a staff team that have the necessary skills and experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of current residents. The management and administration of the home is good, with evidence of consideration being given to residents and/or relatives opinion at all times. What has improved since the last inspection? What they could do better: Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 7 Urgent action was required in order to ensure that the health, safety and welfare of service users is protected at all times, in that the recording of Controlled Drugs entering the home and being administered are to be recorded in a bound, tamper proof book. All bars of soap deemed for communal use are to be removed from bathroom and toilet areas, in order to reduce the risk of spread of infection. Recommendations for good practise have also been made in that all record entries are to be written made in black pen, records of activities attended by residents are to be maintained on a consistent daily basis, advice should be sought from the EHO regarding the safe attachment of the showerhead and the formal quality monitoring system should be expanded upon to include obtaining the views of other stakeholders and interested parties. The results of annual Quality Assurance audits should also be published and made available to all. 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. Marshview DS0000021161.V363702.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 Marshview DS0000021161.V363702.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): 3&6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has processes in place for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: Following the inspection of June 2007 the Registered Provider/Registered Manager has made improvements to ensure that that the pre-admission needs assessment be completed in full and in consultation with the service user or a representative. Documentation relating to the most recent admissions to the home were viewed and found to have been completed fully and conducted with the involvement of the resident and/or their representatives (where applicable). The home’s Registered Manager carries out pre- admission assessments. Copies of care management assessments from the placing authority are Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 10 obtained, where these exist. The Registered Manager addresses any issues, which are highlighted within this assessment. Documented records are maintained of all correspondence with the placing authority. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. Intermediate care is not provided by this home. Marshview DS0000021161.V363702.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 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. All care is administered in way that protects residents privacy and dignity. Medication procedures ensure that all necessary precautions are taken to ensure errors do not occur and that medications are stored and administered safely. EVIDENCE: Following the inspection of June 2007 the Registered Provider/Registered Manager has made improvements to ensure that service users’ care plans set out in detail the action which needs to be taken by care staff, to ensure that all individual health, personal and social care needs are met in a structured and consistent manner. Care plans were sampled and it was evidenced that they were comprehensive, detailed in content and covered all aspects of resident’s needs. Care plans are written to allow the assessor to gain a good overview of individuals medical, mental health, social and personal care needs and provide Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 12 the assessor with a clear overview of the Residents current needs, limitations and required assistance. Residents involvement in the care plan review process was also evident. Since the inspection of June 2007 improvements have been made to ensure that care plans be regularly reviewed and updated to accurately reflect service users current and changing needs. Of the care plans viewed it was evidenced that consistent monthly reviews are maintained and any necessary changes had been made. At the inspection of June 2007 it was required that risk assessments are updated in respect of those service users who are at risk of tissue breakdown and falls. Risk assessments for falls/tissue viability/nutrition were viewed and found to be comprehensive in detail. Monthly reviews of such documentation were also noted. Residents are registered with one GP from one of four local surgeries. District Nurses, the Stoma Nurse and the Continence Nurse all attend the home as needed and are accessed directly by the staff of the home. Domiciliary opticians attend the home yearly and on an as required basis. Dentist treatment is arranged via private and/or NHS surgeries. There are both types of surgeries available locally. Home dental visits are also conducted as required. Access to audiology, physiotherapy, Occupational Therapy and the Dietician are sourced via GP. The home has a Chiropodist who attends the home every six to eight weeks and as required. The home has good procedures in place for the monitoring and recording of all drugs administered, disposed of and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Medication administration records were viewed and these were found to be maintained appropriately. It was evidenced that some entries had been made in red pen, therefore a recommendation has been made. Controlled Drugs are maintained on the premises and were found to be recorded on a sheet of loose leaf paper, which is easy to alter and increases the risk of abuse of Controlled Drugs. Therefore an immediate Requirement was made. This was addressed prior to the conclusion of the inspection and all Controlled Drugs are now recorded in bound, tamper proof book. The Registered Manager is aware of the new guidance for Controlled Drug cupboards and is currently seeking advice from a pharmacist, with a view to purchasing and installing a cupboard, which complies with the new guidance. Staff were observed providing personal support to residents in such a way that promoted and protected their privacy and dignity. Marshview DS0000021161.V363702.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 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a full and stimulating programme of activities to choose from. The home provides a wide range of social, cultural and recreational facilities, including specialist diets to residents, with resident’s choice and wishes being respected. EVIDENCE: Following the inspection of June 2007 the Registered Provider/Registered Manager has made improvements to ensure that service users be consulted regarding their social and leisure interests and an activities programme be implemented to reflect those interests and preferences. There is a published list of activities, which is made available to all residents. Care staff conduct activities and though there is a list, the daily activity can be changed according to residents choice. Records are maintained of all activities conducted, though there were large gaps in the dates of the entries being made and some entries were written in red pen. Therefore a recommendation has been made. Activities include: Bingo, I Spy, quizzes, reminiscence, visiting Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 14 motivation, visiting music and exercise, Bowls, floor sized snakes and ladders, noughts and crosses and DVD/Film afternoons. Residents spoken with said that they liked most of the activities and could ‘pick and choose’ those that they attended. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion, if they wish. Discussions with the Registered Provider/Registered Manager highlighted that although the current residents had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The management of the home believes in promoting an equal and diverse culture among staff and residents. External activities are arranged three to four times a year. Residents, where able, are encouraged to attend the local market town. Three residents attend local weekly church meetings. There are currently no day centre attendees at present. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Following the inspection of June 2007 the Registered Provider/Registered Manager has made improvements to ensure that service users be consulted regarding their social and leisure interests and an activities programme be implemented to reflect those interests and preferences. There is a published list of activities, which is made available to all residents. Care staff conduct activities and though there is a list, the daily activity can be changed according to residents choice. Records are maintained of all activities conducted, though there were large gaps in the dates of the entries being made and some entries were written in red pen. Therefore a recommendation has been made. Activities include: Bingo, I Spy, quizzes, reminiscence, visiting motivation, visiting music and exercise, Bowls, floor sized snakes and ladders, noughts and crosses and DVD/Film afternoons. Residents spoken with said that they liked most of the activities and could ‘pick and choose’ those that they attended. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion, if they wish. Discussions with the Registered Provider/Registered Manager highlighted that although the current residents had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The management of the home believes in promoting an equal and diverse culture among staff and residents. External activities are arranged three to four times a year. Residents, where able, are encouraged to attend the local market town. Three residents attend local weekly church meetings. There are currently no day centre attendees at present. Contact with family and friends is positively encouraged with visitors Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 15 being able to attend the home at any time and in accordance with the resident’s wishes. The homes menus are devised on a four week rolling programme. Menus are planned with residents input. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and residents guests are also welcome to have meals at the home. Meals can be taken in the residents bedroom or in the communal dining room. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Marshview DS0000021161.V363702.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received five complaints within the past twelve months, all of which have been recorded as addressed. Each of the complaints have been resolved and appropriate action was taken by the Registered Provider/Registered Manager, to address the concerns raised. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files were viewed. The Registered Provider/Registered Manager is also ‘Train the Trainer’ qualified in Safeguarding. A copy of the East Sussex County Councils Safeguarding Adults procedures is readily accessible to staff. There have been no Safeguarding Alerts raised by the home in last twelve months. Marshview DS0000021161.V363702.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, 21, 23 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides accommodation for residents that is safe, hygienic and odour free, whilst infection control procedures are adhered to at all times. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. It was observed in the shower room that the showerhead can be detached from the wall and is long enough to reach the toilet. The associated risks of the showerhead being able to be put into the toilet were discussed and a recommendation was made. Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 18 Following the inspection of June 2007 the Registered Provider/Registered Manager has made improvements to that a review is carried out to enable service users to bring in their own furniture. Residents own furniture was noted in some of the bedrooms inspected. The bringing into the home of residents own furniture is also recorded in Statement of Purpose and Service User Guide. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. Staff were observed adhering to infection control procedures. The home was clean and odour free throughout. There is a daily cleaning schedule in place. Marshview DS0000021161.V363702.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 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which details staff designations and hours of working. At the inspection of June 2007 it was required that staffing levels be reviewed to ensure that service users needs are met. It was observed from the duty rota that three staff are on duty in morning. This is an increase from two at the previous inspection. There is currently one staff member who is under eighteen years of age. This person does not conduct care duties and is deployed to complete bed making and laundry duties. Staff spoken with stated that having the extra person in the morning has ‘helped enormously’. The Registered Provider/Registered Manager stated that should a residents needs change then staffing levels would be increased accordingly. The home has a permanent staff team of the Registered Manager, Senior Carer, twelve care staff, two cooks and a cleaner. Seven care staff are National Vocational Qualification, level 2 or above, trained in care and one carer is currently completing the NVQ level 2, in care training. Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 20 Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Training records were observed and it was evidenced that the staff induction training is conducted in line with Care Skills Sector guidance. Mandatory training consists of Fire Safety, First Aid, Food Hygiene, Infection Control, Moving and Handling and Abuse Awareness. Additional training is also provided in dementia, stoma care, diabetes, nutrition, NVQ’s, falls prevention and other subjects that arise from changes in residents needs. Marshview DS0000021161.V363702.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 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents experience the benefits of a home that is well managed and administrated. Consideration is given to resident’s choice and opinion in all aspects of provisions provided. With some improvements required to ensure that the health, safety and welfare of residents and staff are protected at all times. EVIDENCE: The Registered Manager of the home is also the Registered Provider and has owned and managed the home for nearly eight years. The Registered Provider/Registered Manager has achieved the NVQ level 4 and has a City & Guilds certificate in management. Residents spoken with said that the Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 22 Registered Manager was friendly, approachable and always takes residents concerns or comments about the home seriously. Since the inspection of June 2007 improvements have been made to ensure that a formal quality monitoring system be implemented. Six Monthly relative surveys are conducted, the results of which are not currently published. Other stakeholder surveys are also not conducted at present. Therefore recommendations made. Regulation 26 visits not currently required as the Registered Provider/Registered Manager is in the home days a week. Regulation 37 incident reports are sent to CSCI. Residents meetings held four to six weekly and staff meetings are held six to eight weekly, the minutes of meetings held were viewed. The home does not take any responsibility for many of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. Following the inspection of June 2007 improvements have been made to ensure that a fire safety risk assessment is carried out in line with latest fire safety guidance. This was viewed and it was observed that this had been conducted in April 2008. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. On the tour of the premises it was noted that bars of soap deemed for communal use were in many of the homes bathroom and toilet areas. Therefore an immediate requirement was made. Marshview DS0000021161.V363702.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 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 2 Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 (2) Requirement Timescale for action 27/05/08 2. OP38 That the recording of Controlled Drugs entering the home and being administered are recorded in a bound, tamper proof book. This is an immediate requirement. 13 (3) & That all bars of soap deemed for 27/05/08 (4) (a) (b) communal use are removed from (c) bathroom and toilet areas, in order to reduce the risk of spread of infection. This is an immediate requirement. 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. 2. 3. Refer to Standard OP9, OP12 OP12 OP21 Good Practice Recommendations That record entries are written made in black pen. That records of activities attended by residents are maintained on a consistent daily basis. That advice is sought from the EHO regarding the safe attachment of the showerhead. DS0000021161.V363702.R01.S.doc Version 5.2 Page 25 Marshview 4. OP33 That the formal quality monitoring system should be expanded upon to include obtaining the views of other stakeholders and interested parties. The results of annual Quality Assurance audits should also be published and made available to all. Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Marshview DS0000021161.V363702.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!