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Inspection on 14/08/08 for St Mary Magdalene Residential Unit

Also see our care home review for St Mary Magdalene Residential Unit for more information

This is the latest available inspection report for this service, carried out on 14th August 2008.

CSCI found this care home to be providing an Excellent 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

People referred to the home have a thorough assessment of their needs to enable their care to be properly planned. Each resident has personalised care plans that are very well recorded and demonstrate the support they require to meet their needs. Staff treat residents with respect and ensure their privacy and dignity is maintained. People living at the home and their relatives and friends are happy with the standard of care provided. They told us, "The staff are marvellous", "The support my aunt receives is fantastic", and, "They have skills and experience and all the staff are very caring". People receive very good support to meet their individual health care needs, and have medication administered safely. A structured programme of social events is being organised following consultation with residents to make sure stimulating activities are offered. Contact with family, friends and the local community continues to be encouraged. Each person is recognised as an individual with diverse needs and people are supported to exercise control over their lives. New menus are being devised that will include residents preferred meals and meet the nutritional needs of older people. There is a clear complaints process that people are confident to use if they have any concerns about the service. Care workers are trained to protect people from abuse and keep them safe from harm. Good staffing levels are provided and care workers receive training that is specific to caring for older people, including nationally recognised care qualifications. The home has an annual quality plan that sets out how standards will be monitored and improved and this is lead by the needs and wishes of people using the service. The health and safety of residents and staff is promoted through staff training and making sure there are safe working practices.

What has improved since the last inspection?

There is a new registered manager is in post who is very experienced and qualified, and committed to providing a quality service. The refurbishment of the home has been carried out to a high standard so that residents benefit from a more comfortable and accessible environment.

CARE HOMES FOR OLDER PEOPLE St Mary Magdalene Residential Unit Claremont Road Newcastle Upon Tyne Tyne & Wear NE2 4NN Lead Inspector Elaine Malloy Key Unannounced Inspection 14th August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary Magdalene Residential Unit DS0000000458.V370424.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. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary Magdalene Residential Unit Address Claremont Road Newcastle Upon Tyne Tyne & Wear NE2 4NN 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) 0191 2697920 0191 2697921 st.marymagdalene@btconnect.com St Mary Magdalene & Holy Jesus Trust Mrs Carole Diane Smith Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2007 Brief Description of the Service: St Mary Magdalene is a care home that provides personal care for up to 19 older persons. The home has had an extensive refurbishment that was completed in 2008. It is situated in a complex of sheltered housing that is run by the same charity and there is a shared kitchen and dining room. The home has communal lounge and dining areas. All bedrooms are single and seven rooms have en-suite facilities. There is a passenger lift and all parts of the building are accessible. A guide to the home’s services and inspection reports are readily available at the home. The home has contracting arrangements with Newcastle City Council. The current weekly fee is £389 for residents funded by the Local Authority and £440 for residents who are privately funded. St Mary Magdalene Residential Unit DS0000000458.V370424.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 3 star. This means the people who use this service experience excellent outcomes. The inspection was carried out by: • Looking at information received since the last inspection on 24th April 2007. • Getting the provider’s view of the service and how well they care for people. • An inspector visiting the home unannounced on 14th August 2008. • Getting the views of people who use the service and their relatives by talking to them and from surveys they completed. • Talking to the manager and other staff about the service. • Looking at records about the people who live at the home and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they care for. • Looking around parts of the building to make sure it is clean, safe and comfortable. During the recent refurbishment residents had temporarily moved out of the home and spent time in a local hospital. They had returned to the home five weeks prior to the inspection. What the service does well: People referred to the home have a thorough assessment of their needs to enable their care to be properly planned. Each resident has personalised care plans that are very well recorded and demonstrate the support they require to meet their needs. Staff treat residents with respect and ensure their privacy and dignity is maintained. People living at the home and their relatives and friends are happy with the standard of care provided. They told us, “The staff are marvellous”, “The support my aunt receives is fantastic”, and, “They have skills and experience and all the staff are very caring”. People receive very good support to meet their individual health care needs, and have medication administered safely. A structured programme of social events is being organised following consultation with residents to make sure stimulating activities are offered. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 6 Contact with family, friends and the local community continues to be encouraged. Each person is recognised as an individual with diverse needs and people are supported to exercise control over their lives. New menus are being devised that will include residents preferred meals and meet the nutritional needs of older people. There is a clear complaints process that people are confident to use if they have any concerns about the service. Care workers are trained to protect people from abuse and keep them safe from harm. Good staffing levels are provided and care workers receive training that is specific to caring for older people, including nationally recognised care qualifications. The home has an annual quality plan that sets out how standards will be monitored and improved and this is lead by the needs and wishes of people using the service. The health and safety of residents and staff is promoted through staff training and making sure there are safe working practices. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 7 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 St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 8 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. Standard 6 is not applicable as the home does not provide intermediate care. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People have their needs thoroughly assessed and are assured these can be met before moving into the home. EVIDENCE: The manager and general manager are updating the home’s Service User Guide to reflect changes to the environment and the new manager’s details. Each resident who completed a survey said they have received a contract and were provided with enough information before moving in so they could decide if it was the right place for them. One person said information about the home was well explained. A relative commented, “As a family we were also invited on a few visits before we were sure this was going to be mother’s new home”. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 9 No new residents have been admitted to the home since January 2007. At the time of the inspection referrals to the service were ‘on hold’ until work in the building is complete. The manager or team leader will visit prospective residents and carry out a detailed assessment of their needs. The person, their relatives and other professionals are involved in the assessment. This includes obtaining the social worker’s assessment and care plan, and requesting medical information from the person’s doctor. The admission procedure for people admitted for respite stays has been reviewed. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 10 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 the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service receive a high level of individualised care and support that respects their privacy and dignity. EVIDENCE: A range of assessment tools is used to identify each person’s physical and mental health needs and risks associated with caring for individuals. Staff were in the process of updating resident care plans to make sure they reflect people’s current needs. Care plans continue to be well detailed and personalised to the individual’s preferences. The sample of plans examined addressed needs relating to personal care, mobility, health conditions, finances, night care and psychological, social and spiritual needs. The records demonstrated the person’s independent abilities and described specifically the support staff provides. Potential risk factors are included and the plans show St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 11 how these are managed. Where necessary, plans are drawn up for short term needs, for example when a person has an infection or injury. Care plans are evaluated at least monthly, and more often if required. Staff record daily reports that cross-reference to care plans and maintain additional records for personal hygiene, weight monitoring and social activities. The home has a system to review individual’s care at least six monthly. Residents who completed surveys and spoke with inspector said they receive the care and support they need. Comments included, “I am very well looked after”, “They are kind and caring”, and, “Nothing is a trouble to the staff”. Relatives/friends said they feel the care home meets the needs of their family member or friend and gives the care they expect. One person said, “The support my mam gets is brilliant”. Each person’s moving and handling, risk of falls, nutrition and continence needs are assessed. There was clear evidence of any concerns about resident health being promptly followed up. For example, contact to medical professionals, referrals for specialist support, provision of treatment/aids/equipment and very good examples of care plans for acute and chronic health conditions. Residents said they receive the medical support they require. Five GP practices are used. The allocated District Nurse was currently visiting a resident three times weekly. Records are kept of all contact with health professionals and hospital appointments. This includes input from doctors, District Nurses, optician, chiropodist, dentist, phlebotomist, physiotherapist and a psycho-geriatrician. Each person is asked if they wish to administer their own prescribed medication, to encourage independence. One resident self-administers their medication and an assessment of the risks has been completed. All care staff have undertaken medication training. Medication is kept in alarmed storage. The radiator in this room is to be turned down or off to make sure suitable temperatures are maintained. A sample of medication records was examined. Resident photographs, for identification purposes are being updated. Medication charts were appropriately completed. The manager is following up the issue of unspecific pre-printed directions on medication charts with the supplying pharmacist. Each resident spoken with indicated that staff are polite and respect their privacy and dignity. All personal care and treatment is carried out in the privacy of the resident’s own room. Residents are asked how he/she wishes to be addressed and if they prefer male or female care workers to assist them with personal care. Staff also ask the person’s permission for care staff to check on them during the night, and record their agreement. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 12 Each bedroom is single occupancy and there are now seven rooms with ensuites with shower and toilet facilities. Telephones with personal direct number are available in every bedroom. The call system has been upgraded and residents have a pendant to be worn around the neck that enables them to summon staff help. Personal mail is given directly to the person and staff will support residents with reading and dealing with correspondence. St Mary Magdalene Residential Unit DS0000000458.V370424.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are well supported to live their preferred lifestyle and are actively encouraged to maintain relationships and contact with the community to meet their social needs. EVIDENCE: Residents have their social needs assessed, including lifestyle, routines and interests, and social care plans are in place for each person. Individual records of activities the resident has participated in, and visitors are kept and a social diary is also recorded. Activities provision has been flexible according to residents’ wishes, whilst they settle back into life in the home. Group activities, local outings and one-to-one time with staff have been provided. Residents are supported to pursue their individual interests and are free to join in with the activities organised on the complex. Residents have also been encouraged to plant their own hanging baskets and tubs and make more use of the grounds in good weather. For example, residents had recently taken high tea on the veranda, with music St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 14 playing. People who completed surveys said there are activities arranged by the home that they could take part in. A more structured programme of activities, entertainment and outings is being developed. The home uses community transport and a trip to North Shields was planned. Resident/family forums are starting up again. The manager said part of these meetings would be used to establish people’s preferences and suggestions for social activities and destinations for outings. A voluntary organisation based in the West End of Newcastle is working with the home. It is providing a volunteer to befriend residents and a project is being negotiated. Links are also forged with two schools and residents have been invited to a matinee of an operatic performance at the Performing Arts Centre, courtesy of the Royal Grammar School. A Minister from the Church of England conducts a weekly in-house service and other services are held throughout the year to celebrate specific events. Residents can receive visits from clergy from other religious denominations. The home has an open visiting policy and resident’s social care plans incorporate maintaining contact and relationships with family and friends. The manager said there is an ethos of ‘sharing the care’. Therefore if family/friends wish to continue to support the person with aspects of personal care, socially, doing laundry etc, then this is encouraged. Relatives are invited to attend meetings and individual’s care reviews. The Trustees continue to visit the home regularly and visit individual residents by appointment. Relatives/friends said the home helps their relative/friend to keep in touch with them. They said they are always kept up to date with important issues affecting their relative/friend. One person commented, “If at any time mam is unwell or the home needs to speak to us they get in touch straight away”. Another said, “I have always been informed when my aunt is admitted to hospital. They also visit my aunt and we keep in contact the whole time my aunt is in hospital”. The home has introduced a new policy on equality and diversity. There are also policies on residents maintaining their preferred lifestyle, personal autonomy and exercising choice. These are put into practice by ensuring people are consulted so they can make informed choices and retain independence. Relatives/friends are involved to advocate on the person’s behalf where necessary. Examples of this include residents being consulted throughout the process of the home’s refurbishment, choosing their bedroom and the colour theme of soft furnishings. Each resident has a care plan for his/her personal finances that details whether they manage their own finances or the support they need. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 15 The manager said she is looking towards a more pro-active approach to involving residents in their personal care planning. Relatives said the service supports people to live the life they choose and meets the different needs of people. Comments included, “We are advised of any changes to care plans and complete six monthly reviews with staff”, and, “Encourage residents to participate but respect wishes if they dont. Staff very accommodating with frequent visitors and this is important to my grandmother”. Each resident has an assessment of their nutritional needs and weights are monitored. A good example was seen of a dietary care plan for a resident. Meal times are flexible and residents can choose when and where to eat. People take meals in their bedroom or the dining room in the home, and they are using the main dining room on the complex more often. Catering staff have looked at portion sizes in response to residents comments about these being too large. The inspector dined with residents at lunch in the main dining area. The tables were nicely set and a range of condiments was available. Hot and cold drinks were served. The starter was a choice of soup or fruit juice. The main meal was scampi and chips with peas or lamb chops, potato, broad beans, turnip and gravy. Dessert was ginger sponge and custard or fruit and ice cream. Staff were attentive but not intrusive and offered people choices and discreet assistance. Each resident spoken with said they enjoy the food, and confirmed they can request alternatives. One resident who completed a survey said, “The meals are very good. There’s plenty of choice and the chef makes them look appealing”. Another person said, “I ask for small portions as the meal sizes are generous”. Menus are currently planned weekly and residents are asked their choice of meals on the day. The senior cook has attended training on healthy foods, special diets and providing good nutrition to older people. She is meeting with the manager to revise the cycle of menus to incorporate resident requests and include seasonal dishes. Breakfast and snack suppers will be included within the menu. St Mary Magdalene Residential Unit DS0000000458.V370424.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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service are properly protected from harm by effective procedures for making complaints and safeguarding vulnerable adults. EVIDENCE: Records of comments and compliments about the service are kept, including cards and letters. Residents are given a copy of the home’s complaint’s procedure in the guide to the service. No complaints have been made in the period since the last inspection. The manager is aware that records must be kept of the nature of complaint, investigation and action taken as a result. Residents and relatives who completed surveys said they know how to make a complaint. One person commented, “The senior staff are always ready to listen”. Another said, “They are easy to talk to about any concerns”. Staff who completed surveys said they know what to do if a resident or relative/friend/advocate has concerns about the home. One person said, “They can fill in a complaints form, or if a resident confides in me and I cannot reassure the resident myself then I will speak to the senior on duty in a confidential manner to sort out any concerns”. The home has policies and procedures on recognising and preventing abuse, protection of vulnerable adults (POVA), and ‘whistle blowing’ (informing on bad St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 17 practice). No allegations of abuse have been made. All staff have received safeguarding training in conjunction with Newcastle Social Services. The manager understands her role in reporting any allegations to the relevant authorities. One resident said, “I am very happy here. I feel safe here and the staff are very kind”. St Mary Magdalene Residential Unit DS0000000458.V370424.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 the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service live in a clean, safe environment that has been upgraded to a high standard for their comfort and is well equipped to meet their needs. EVIDENCE: An extensive refurbishment, undertaken in stages has been completed this year. Residents, relatives and staff were involved in the refurbishment plans. The residential unit is now self-contained and there is a fob key system for entry and exit. The doors to the entrance open automatically and doorways in the building have been widened to accommodate people using mobility aids. The home has had a new roof and UPVC windows; new mechanical and electrical installations including upgrade of the passenger lift, and telephone, St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 19 emergency call and fire safety systems. Window cills are lower and enable residents to have a better view of the grounds. Seven bedrooms have been provided with large en-suite shower and toilet facilities. Larger lounge, dining and laundry rooms have been created. All bedrooms, communal living areas and corridors were decorated and have new furnishings and carpets. Toilets are equipped with aids and grab rails. There is now office accommodation on both floors and improved staff changing areas. There are plans for the handypersons to decorate the bathrooms and carry out repairs, and for the small kitchen to be refitted. All parts of the building seen were clean and odour-free. Residents said the home is always fresh and clean. The home has policies and procedures on maintaining good hygiene and infection control. Staff are trained in infection control and the team leader is the link person to attend meetings with the local Health Protection Agency. Staff are supplied with protective equipment to carry out tasks safely, such as disposable gloves and aprons. Suitable hand-washing facilities are provided. The upgraded laundry room has separate ‘wet’ and ‘dry’ areas. Arrangements are in place to dispose of clinical waste. St Mary Magdalene Residential Unit DS0000000458.V370424.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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Skilled and competent workers who are trained to meet people’s diverse range of needs care for residents. EVIDENCE: At the time of the inspection there was reduced resident occupancy of eight people. Care staffing levels of at least three workers across the day and two workers at night were being maintained. Domestic cover is provided between 8.00am and 7.00pm most days. A good level of catering staff hours is provided. A security firm is employed to patrol the grounds at night. Residents said that staff listen and act on what they say, and are available when they need them. Relatives/friends said staff have the right skills and experience to look after people properly. Three care workers completed surveys. Each indicated their recruitment was fair and thorough and that they received good induction, ongoing training, and support from their manager. One person said, “My induction was very good, covering health and safety, fire training, and rules and regulations. I was also given the policies and procedures to read and was asked a number of questions to make sure I understood. I was also shadowed by a senior or St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 21 another member of staff for a few weeks”. All said training is relevant to their role, helps them understand and meet individual resident’s needs and keeps them up to date with new ways of working. Workers said they are given up to date information about the needs of the people they support and staff communication about residents works well. One person said, “Up to date information about the needs of the residents is always written in the care plans. Also staff are given a handover at the start of each shift so that we are all given the same information”. Staff said they have enough time to meet people’s assessed needs and the right support, experience, and knowledge to meet the different needs of people who use the service. Additional comments included, “Our service meets the needs of our residents by offering well trained staff, good accommodation and food, and meeting high standards of care”, and, “I think St Mary Magdalene is a pleasant unit to work in. The staff are very friendly and the residents are very well cared for. The overall standards are very high and always maintained. Everyone works together to ensure that the residents are safe and happy within their home”. 72 of care and senior staff has achieved National Vocational Qualifications (NVQ) in care at Level 2 or above. The manager confirmed that the home has followed up on the recommendation made at the last inspection to introduce a declaration statement of physical and mental fitness to recruitment information. One new domestic member of staff has been employed in the past year. This person’s recruitment file was not examined, as it was unable to be accessed. At the last inspection the home demonstrated a robust recruitment process, including all staff being recruited subject to Criminal Records Bureau checks being carried out. New staff are provided with induction training to Common Induction Standards. The home continues to have good links with a range of training providers. Individual records of training and certificates are kept for each staff member. In the past year staff have received training in safeguarding vulnerable adults, supporting people at the end of life, equality and diversity, first aid and food hygiene. Further updates of safe working practices training was organised. Two staff are starting a course on hand and head massage and aromatherapy next month. The manager was looking towards arranging more training on equality and diversity issues, mental health and caring for people with dementia. She also intends to continue regular in-house training on different topics. St Mary Magdalene Residential Unit DS0000000458.V370424.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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are provided with a quality service that is managed in their best interests and promotes their safety and welfare. EVIDENCE: In June 2008 the Commission for Social Care Inspection (CSCI) approved Mrs Carole Smith as the Registered Manager for the home. She has over 30 years experience in care, and has achieved social work, management and personnel qualifications. She has 24 hours per week supernumerary time for management duties. St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 23 Mrs Smith has held staff meetings and has carried out individual supervision sessions with staff. She has spent time working with residents to understand their needs, including visiting residents when they stayed temporarily in hospital during the home’s refurbishment. She is supported in her role by the senior staff team, the General Manager, the Board of Trustees, and the manager of the domiciliary care service on the complex. Administrative support is also provided. An annual development plan to monitor and develop the quality of the service is in place. This includes consultation with residents and their families and friends through meetings and surveys, activities, care plans, volunteers, the environment and gardens, and staff training, supervision and meetings. The manager will make sure that all methods are measurable and where necessary that audits are carried out. Monthly ‘conduct of home’ visits and reports by Trustees/General Manager are to recommence this month. Policies and procedures are being reviewed. Comments from relatives/friends on the quality of the service included, “They look after our mam and her needs very well, which is our number one concern. I feel she would not get any better looked after elsewhere”, “The staff are all very friendly towards me and are very attentive towards my friend”, and, “Standard of care is very good. Willing to meet my grandmother’s and my needs. Her health has deteriorated since she first went into the home and they have accommodated all changes”. Positive comments were also made about the home’s refurbishment and the ability of staff to work well during this time. As previously stated, each resident has an individual care plan for managing personal finances. People can choose to have cash held in the home’s safe for personal spending. Records of accounts were examined. These were appropriately recorded and receipts are obtained for purchases. There are two signatures for each transaction, and the resident or their relative signs where possible. Weekly checks of cash and balances are carried out. A full health and safety audit was conducted before residents moved back into the home. Regular ‘snagging’ inspections are being carried out and risk assessments are being updated. The home has a health and safety policy and range of associated procedures. Staff are trained in health and safety and safe working practices. There are servicing and maintenance agreements for facilities and equipment. Good systems are in place to ensure fire safety, safe moving and handling, first aid, food hygiene, infection control and accident reporting. The catering services for the complex have achieved the highest star rating for food hygiene from Newcastle City Council. St Mary Magdalene Residential Unit DS0000000458.V370424.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 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 4 X X X X 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 3 St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 25 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations St Mary Magdalene Residential Unit DS0000000458.V370424.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 St Mary Magdalene Residential Unit DS0000000458.V370424.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. 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