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Inspection on 19/08/08 for Queen Mary`s and Mulberry House Nursing Home

Also see our care home review for Queen Mary`s and Mulberry House Nursing Home for more information

This is the latest available inspection report for this service, carried out on 19th August 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The registered manager and supporting team are committed in providing a good standard of care within a homelike and friendly atmosphere, where communication between staff, residents and visitors is positive open and friendly. Visitors are made to feel very welcome and are seen as an important part of the home. Visiting times are not restricted. The care provided is reviewed regularly and takes into account community health care resources involving them whenever needed. This provides a multidisciplinary approach to care. Health care professionals were supportive of the care provided `they looked after one resident with very high needs very well they were marvellous`. Residents are encouraged to engage in the activities and entertainments provided in the home and also have individual time with the activities coordinator if desired. One visiting professional commented on the activities in the home and said `there is always something going on` All parts of the home were clean, comfortable and well maintained.

What has improved since the last inspection?

The home continues to be maintained and redecorated to a good standard. The Medicine Administration Record (MAR) charts clearly record the prescribed individual medicines. Those medicines that expire shortly after opening like eye drops are now dated when opened. An audit of medicines is now completed. Medical equipment is appropriately stored and maintained. The sharps bin was found to be available and safe for use.

CARE HOMES FOR OLDER PEOPLE Queen Mary`s Nursing Home 7 Hollington Park Road St Leonards On Sea East Sussex TN38 0SE Lead Inspector Melanie Freeman Unannounced Inspection 19th August 2008 10:00 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 Queen Mary`s Nursing Home DS0000014031.V369425.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. Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Mary`s Nursing Home Address 7 Hollington Park Road St Leonards On Sea East Sussex TN38 0SE 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) 01424 728800 01424 427176 qm@galleoncare.co.uk Galleon Care Homes Limited Ms Julie Lowes Care Home 72 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users 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 (OP) 2. Physical disability (PD). The maximum number of service users to be accommodated is 72. Date of last inspection 12th September 2006 Brief Description of the Service: Queen Marys is a large adapted house situated in a quiet residential area of St Leonards on Sea. It has two purpose built extensions the second of which was registered in April 2007 increasing the homes registration from 53 to 72. Bedroom accommodation is provided over three floors with shaft lifts fitted to ensure level access to all areas of the home for residents. There are large communal landscaped gardens and patio areas to three sides of the home. Local shops are approximately half a mile distance and St Leonards town Centre with its access to bus and rail routes approximately one mile away. Queen Marys is registered to accommodate up to 72 older people who require nursing care and who may have a physical disability. Queen Marys is owned by Galleon Care Homes Ltd, which was purchased in April 2008 and became part of Titleworth Healthcare Ltd Group along with the two sister care homes within East Sussex. Copies of inspection reports and the homes statement of purpose are made available on request. Fees charged as from August 2008 range from £550 to £668 depending on the room occupied. Additional charges are made for Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 5 hairdressing, chiropody, newspapers, personal toiletries and some outside activities such as visits to the theatre. Intermediate care is not provided. Queen Mary`s Nursing Home DS0000014031.V369425.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 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Queen Mary’s will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with visiting health and social care professionals. The allocated inspector spent approximately six hours in the home and was able to provide feedback to the deputy manager at the visits conclusion. A brief tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to five residents were reviewed in depth and the inspector ate a midday meal in the dining room. Comments shared by residents and their representatives during the inspection process included ‘I cannot fault the place’ ‘Everything is perfect’. Information provided by the home within the Annual Quality Assurance Assessment (AQAA) has also been included in this report. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from one resident and two staff members. What the service does well: The registered manager and supporting team are committed in providing a good standard of care within a homelike and friendly atmosphere, where communication between staff, residents and visitors is positive open and Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 7 friendly. Visitors are made to feel very welcome and are seen as an important part of the home. Visiting times are not restricted. The care provided is reviewed regularly and takes into account community health care resources involving them whenever needed. This provides a multidisciplinary approach to care. Health care professionals were supportive of the care provided ‘they looked after one resident with very high needs very well they were marvellous’. Residents are encouraged to engage in the activities and entertainments provided in the home and also have individual time with the activities coordinator if desired. One visiting professional commented on the activities in the home and said ‘there is always something going on’ All parts of the home were clean, comfortable and well maintained. What has improved since the last inspection? What they could do better: The procedure followed with regard to admitting any resident to the home must ensure a suitable assessment is completed by a competent person before admission. This will ensure that those residents that are admitted to the home can have all their care needs met. The care documentation needs to be improved to demonstrate that resident or their representatives are involved in planning the care to be delivered. The administration of medicines must be improved to ensure the homes procedures are adhered to and the Nursing and Midwifery Council guidelines are followed at all times. This will ensure that all medicines are administered and stored safely. The recruitment procedures must be improved to ensure all the required checks are completed and relevant documentation is held on file. This will ensure safe recruitment practice is followed at all times and in turn safeguard residents living in the home. Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 8 The systems for holding residents money and valuables need to be supported with clear procedures to ensure residents money and valuables deposited for safekeeping are dealt kept safely with suitable records. 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. Queen Mary`s Nursing Home DS0000014031.V369425.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 Queen Mary`s Nursing Home DS0000014031.V369425.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 and 3 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The admission procedures ensure that all prospective residents that are to be permanent placements are fully assessed by a competent person before admission, and are assured that their needs can be met by the home, this however is not the case for all residents receiving respite care. Intermediate care is not provided at Queen Mary’s. EVIDENCE: Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 11 The home has a statement of purpose and a service users guide. This was available on request and was held in a folder along with the latest Annual Service Review (ASR) completed by the commission a brochure of the home and other useful booklets for advice and guidance. The last key inspection report was available on request. A review of the statement of purpose and service users guide indicated that it needed to be updated to reflect the change of the homes ownership and to ensure it contained all the required information. For example it should record the number and size of rooms in the home, and the homes fire precautions and the organisational structure. The deputy manager confirmed that this updating would be progressed. A visiting relative said that she had good information about the home and its services before her husband was admitted. An assessment of the admission process followed included the review of the documentation relating to the last three admissions to the home. This confirmed that those residents that are admitted to the home on a permanent basis are subject to a full pre admission assessment. These are completed either by the registered manager or her deputy, ensuring that the home has the staff, equipment and environment to meet the care needs of the new resident. This is then confirmed in writing to the prospective resident or their representative, stating on what basis the decision is reached. A resident who had been admitted for respite care had not had his needs assessed prior to admission. Although it is acknowledged that the admission was in response to an emergency, the decision to admit appears to have been made by the administrator and written information from the care manager was not obtained. It was also noted that once this resident was admitted a full update and review of his previous care documentation was not completed. Clearly the admission procedure needs to ensure suitable assessment processes are in place for all residents be it for respite or for a permanent placement and even if it is in response to an emergency. This shortfall was raised and discussed with the deputy manager at the conclusion of the inspection visit. Queen Mary’s does not provide intermediate care. Queen Mary`s Nursing Home DS0000014031.V369425.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 and 10 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individual plans of care set out residents needs and care is delivered in such a way that promotes and protects the residents’ privacy and dignity. With residents health care needs being supported by community resources as necessary. The systems for the safe administration for medicines need to be improved with safe procedures being followed at all times. EVIDENCE: The care documentation pertaining to five residents were reviewed as part of the inspection process. These were found to include extensive plans of care Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 13 that cover the physical, psychological and social care needs of residents. Nutritional screening, moving and handling and pressure area risk assessments are used routinely and other risk assessments are used as needed. Base line observations are completed regularly to monitor changing health needs. On the whole the care documentation was full and demonstrated that the care was reviewed and evaluated. It was however it was noted that resident consultation and agreement was not recorded and liquid paper was used to change records. These matters were raised with the deputy manager who advised that the use of liquid paper would be stopped and that she was unaware that it was being used. Records seen indicated that the home works closely and in consultation with a wide variety of specialist health care professionals, and contact with them confirmed that this was a productive relationship that benefited residents. Staff spoken to demonstrated a good understanding of resident’s individual care needs and they were able to discuss the choices that residents had made with regard to these. Staff read and update the care documentation and were seen to receive a hand over report at the beginning of their shift where they have an opportunity to discuss and reflect on the care provided. All feedback about the home was positive about the standard of care provided. Observation on all units of the home demonstrated good practice was being followed in respect of the medicine administration and registered nurses administer all medicines. However it was noted that two tablets that were left with a resident were not taken, although the Medicine Administration Record (MAR) chart indicated that they had been. In addition a Temazepan tablet administered had not been double signed as required by the homes procedure. The administrations of prescribed creams were also not being recorded on the MAR charts. These shortfalls were raised with the deputy manager who said that she would address these matters with the staff concerned. Both clinical rooms were found to be tidy and well organised. As a matter of good practice it was recommended that photographs were attached to MAR charts and that any medicines administered on an ‘as required basis’ is done so in accordance with individual guidelines. Staff rapport with residents and visitors was seen to be respectful with staff taking the time to know residents and always asking them or advising them of what was happening. Resident’s rooms are seen as their own personal accommodation and those viewed were attractive and personalised. Queen Mary`s Nursing Home DS0000014031.V369425.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 and 15 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Social activities and entertainment are creative and provide variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. People in the home benefit from a choice of meals but the quality of the food is variable. EVIDENCE: The routines in the home are as flexible as possible, with residents able to choose their daily schedule when they are able to, including their meal times and venue. Discussion with residents confirmed a satisfaction with life in the home and it was seen that they made choices about where they spent their time and what they did. Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 15 There is one activity co-ordinator employed and one assistant co-ordinator and activity sessions take place three times a week. Regular surveys are completed to ensure what is being provided is reflective of what is wanted. Activities include baking, gardening, trips out, clothes parties, music and reading sessions and craftwork. There are regular one to one sessions for those residents that do not attend activities and this could include trips out in a car, shopping trips or just a chat in their bedroom. The care plans illustrate their individual social needs and how the staff meet them. Queen Mary’s has a high number of visitors this was evident during the inspection visit, and those spoken to commented on how they felt really welcome in the home. A positive relationship was seen and staff were available to transfer residents to quieter areas in the home for visiting. Visitors said they were always offered beverages and ‘made very welcome’. The meal eaten by the inspector with the residents was found to be satisfactory. Residents are given choices and these were responded to. Staff were seen to be supportive to residents ensuring that they were helped as necessary. Feedback from residents and visitors about the food suggested an improvement in the quality is needed to ensure a good standard is maintained at all times. Comments included ‘the food is up and down and depends who is on duty’ ‘the food is a bit tasteless and not cooked as well as it should be’ ‘the food is not bad’. The AQAA recorded that the home has engaged an external consultant to work with them on ensuring a quality service within cost parameters. Queen Mary`s Nursing Home DS0000014031.V369425.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 and 18 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that any complaint would be listened to and responded to appropriately. Staff training and information in the home ensures that any Safeguarding Vulnerable Adult issue would be responded to appropriately when identified. EVIDENCE: The home has a clear complaints procedure and a copy of this is available within the service users guide and displayed on the wall in the entrance hallway. There has been two complaints received since the last inspection and both have been responded to. One related to a heating problem, which was dealt with and the other was an anonymous concern raised around an unnamed staff member. Limited information made this difficult to investigate but the manager did address as far as she could. Records confirmed that the home takes complaints seriously and responds to them with a view to improving the services. Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 17 Everyone spoken to said that they would feel confident to raise a concern with senior staff in the home. One relative saying ‘I have a good relationship with the staff, I feel that I have bonded with them and would feel able to make a complaint if needed’. The home has relevant policies and procedures on the protection of vulnerable adults, which include a whistle blowing procedure, and staff have received appropriate training. The management team has a clear understanding of adult protection issues and have reported matters of concern and participated in strategy meetings held by social services recently. There however needs to be a record of any safeguarding vulnerable adults referral and investigation to demonstrate action taken by the home. Queen Mary`s Nursing Home DS0000014031.V369425.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 and 26 People who use this 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 a comfortable, clean and safe environment for those living in the home and visiting. EVIDENCE: Queen Mary’s is a converted building that has been subject to extensive up grading and two purpose built extensions that have improved the facilities to meet the National Minimum Standards and meet residents needs. The home has attractive gardens and a patio area where residents can sit when weather allows. The communal space in the home is well used and residents benefit from the light and airy environment and different areas that can be used for a variety of uses. Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 19 A tour of the home confirmed that the home is well maintained and decorated in all areas. The home wash fresh and clean and a resident said that the cleaning was ‘very good’. Practice observed during the inspection visit confirmed good infection control practice was being followed with appropriate equipment being readily available. The laundry area was well organised with a clear separation of clean and dirty laundry. Residents clothing was seen to be laundered, and ironed as necessary. The deputy manager was advised of the most recent infection control guidelines from the Department of Health ‘Infection control guidance for care homes’ and she confirmed that she would source these. Queen Mary`s Nursing Home DS0000014031.V369425.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 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix provides a competent and well-motivated staff team that meets residents health and personal care needs, staff training however needs to be maintained. The homes recruitment practice needs to be improved to ensure all the necessary checks are completed in respect of all staff to safeguard residents. EVIDENCE: At the time of this inspection visit the home was occupied by 55 residents and staffing levels observed were found to be appropriate to meet the needs of residents, and records held by the home confirmed that these levels are maintained over the week. The home is divided into three discreet areas for staffing and so staff work in teams supporting each another and reporting to a registered nurse taking charge of that unit. Despite this allocation staff are expected to work across areas when needed. Residents, staff and relatives spoken to thought that there were enough staff to look after the residents well. One staff survey however indicated that further staffing would allow for more individual time. Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 21 Discussion with the deputy manager confirmed that staffing levels were flexible and responsive to the resident’s dependency and occupancy across the whole home. The staffing structure provides a registered nurse in all units with supporting senior carers that have obtained a National Vocational Qualification (NVQ) in care at level 2 or above. This gives a good level of skill and allows for the supervision of staff at all levels. All feed back about the staff was positive one relative saying that you ‘could not fault the staff all are very nice and kind’. Staff did express through the inspection process that they are feeling uncertain following the recent purchase of the home by Tileworth Health care. The management need to ensure that there is plenty of opportunity for staff to express their concerns and to feel that they are being listened to. It is acknowledged that staff meetings are held but at this time of change they need to be increased along with individual support. The recruitment files pertaining to three staff were reviewed as part of the inspection process and were found to include an application form evidence of references and the required Criminal Records Bureau (CRB) and POVA checks on all staff. It was however noted that one staff file only had one reference and two of the files were without photographs. Terms and conditions of employment were not available in the employment files in the home, and were said to be held at head office. There was evidence in the home that full induction training is completed by all new staff and a high percentage of care staff have completed an NVQ in level 2 or above. Although there was evidence in the home to confirm a rolling programme of training was being maintained most of the previous year. This has not been maintained since the change of ownership. The deputy manager advised that all training is being reviewed and is to be restructured. Queen Mary`s Nursing Home DS0000014031.V369425.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): 31, 33, 35 and 38 People who use this 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 qualified and competent manager who takes into account resident’s views to improve the quality of care and services in the home. Resident’s financial interests are safeguarded although records relating to valuables held on behalf of residents need to be improved with a clear procedure to follow. Systems are in place to protect the health, safety and welfare of residents and staff. EVIDENCE: Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 23 The registered manager is a registered nurse and has the experience to run the home effectively; she is supported by a deputy manager and a team of registered nurses. The management structure of the home is competent and provides clear leadership. The manager was on holiday at the time of this inspection and the home was found to be well organised and managed in her absence. The home has various systems in place to review the quality in the home and this includes regular auditing and the use of resident questionnaires that are reported on. Evidence in the home indicated that these had not been used for 2007 or 2008 yet and this was raised with the deputy manager who believed that a report had been completed but could not locate it. The new owners of Queen Mary’s need to re-establish clear systems to monitor quality in the home. Although the homes administration confirmed that some monies and valuables are held by the home for residents and that some records are held, she did not follow a procedure with regard to this. A clear policy and procedure needs to be established and follows to safeguard residents valuables and staff involved with this process. The home has health and safety policies and procedures and these are currently being reviewed and updated by the registered manager. There was evidence in the home to confirm environmental risk assessments are completed regularly. Although there was a letter confirming the fire risk assessment had been completed in 2007 this was not available in the home. The administrator agreed to chase this matter up and ensure this is returned to the home. The deputy manager confirmed that the hot water is checked in the home to ensure this is supplied at a safe temperature. Queen Mary`s Nursing Home DS0000014031.V369425.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 3 X 2 X X X 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 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 25 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 OP4 Regulation 14 (1) That the registered person ensures that a competent person assesses the prospective resident before admission and a copy of this assessment is obtained by the home when this is not completed by the home to inform the admission process. 2. OP7 15 2 (c) Plans of care are composed and reviewed with input from the resident and or their advocate, unless the offer is declined. 3. OP9 13 (2) The administration of medicines must be in accordance with the homes procedures and the NMC guidelines at all times. These should include records for the safe administration of prescribed creams. 4. OP29 19 (1) The registered person must ensure that the necessary checks and records are completed and held in respect of each Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 26 Requirement Timescale for action 01/09/08 01/09/08 01/09/08 01/09/08 employee. This must include two suitable references. 5. OP35 16(2) Suitable procedures need to be implemented and followed to ensure residents money and valuables deposited for safekeeping, are dealt with appropriately, safely and with suitable records. 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Mary`s Nursing Home DS0000014031.V369425.R01.S.doc Version 5.2 Page 27 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 Queen Mary`s Nursing Home DS0000014031.V369425.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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